Patient Assessment Form

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  • 1 is no pain, 10 is the worst pain
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  •   Consent To Treatment

    Within the Athletic Therapist and Osteopathic Manual Practitioner's scope of practice, a treatment includes manual therapy where the practitioner may place their body or hands in contact with your body to administrator treatment. Areas that may be treated, depending on your condition, could include your pelvis, chest wall, abdomen or work within your mouth. If treatment is required within the mouth, such as in the case of TMJ dysfunction or injury, a latex-free glove will be worn. You may be asked to remove clothing in the area to be treated to help facilitate treatment but this will be up to your leave of comfort. If you do not feel comfortable with a given technique being used within your treatment please let Carolyn know immediately. This technique will then be discontinued or modified to your level of comfort and satisfaction. Also following a treatment you may experience some mild soreness that should resolve in 1 to 2 days. If it does not please notify Carolyn. A cancellation/no show fee, in the amount of your full appointment fee, will be applied to any missed appointment without a 24 hours notice given. By signing this consent form you are giving your consent to Carolyn Zepf in the capacity to provide treatment on your person and that you understand and agree to the terms outlined above.

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