Intake Form | Kinematics with Kelly

There are other conditions that require consideration so please answer the following questions:

Are you taking blood thinners?

Yes

No

Are you pregnant?

Yes

No

Are you receiving any treatments or have a medical condition effecting your immune system?

Yes

No

Do you have any known disease or infection that can be transmitted through bodily fluids?

Yes

No

Have you experienced an allergic skin reaction to metals like chromium or nickel?

Yes

No

Do you have any medical devices or implants anywhere in your body?

Yes

No

Have you had any surgical procedures?

Yes

No

Patient’s Consent:

I have read and fully understand this consent form and attest that no guarantees have been made on the success of this procedure related to my condition. I am aware that multiple treatment sessions may be required, thus this consent will cover this treatment as well as subsequent treatments by this facility. All of my questions, related to the procedure and possible risks, were answered to my satisfaction. My signature below represents my consent to receive dry needling and my consent to any measures necessary to correct complications, which may result. I am aware I can withdraw my consent at any time.

I,

Short answer

read and understand the risks, all of my questions have been answered, and I am willing to be treated with dry needling.

Date picker

Patient or Authorized Representative Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Intake Form:

Patient’s Consent: