CONSENT FORM FOR EXAMINATION AND TREATMENT OF THE

NECK AT MANUALWORLD

By signing this form, I declare that I agree to the examination and treatment of my neck. I also acknowledge that I am aware of possible unexpected side effects and complications that may arise from the treatment. These have been explained to me verbally, and I have understood them.

I know where to find more information about these side effects and the treatment:

https://fysiomanueletherapie-schalkwijk.nl/mt-cwk/

Client’s name: Ms./Mr. _______________________________

Date of birth: _______________

During the consultation about examination/treatment, attention has been given to:
● The content of the examination and treatment
● Possible benefits and risks of the proposed treatment
● The possibility to ask questions
● The patient’s right to choose an alternative treatment

Amsterdam / Haarlem, –-________

Signature of therapist: _____________________________

I hereby declare that:
● I have been sufficiently informed about the proposed treatment
● I have understood this information
● I consent to the proposed treatment being carried out
● I consent to examination, mobilizations, manipulations, and exercise therapy of the neck

Amsterdam / Haarlem, –-________

Signature of client: _______________________