Ultrasound Contraindications: An area of the body where a malignancy is known to be present An acute infection or sepsis Pregnancy Deep Vein thrombosis (DVT) Arterial Disease An anesthetized area or condition that causes impairment of sensation, such as chemotherapy Cardiac pacemaker A healing fracture Ischemic tissue in individuals with vascular disease where the blood supply would be compromised Any metal in the body I, _________________________________, have read the above statement and to the best of my knowledge do not have any of the above listed contraindications to the use of the electric stimulation and ultrasound equipment. ___________________________________________ _____________________________________ Signature Date Barnes Family Chiropractic 130 Canal St., Suite 603, Pooler, GA 31322 (912) 748-3755 Fax (912) 748-3031 Authorization to Release Patient Records I hereby authorize Barnes Family Chiropractic, 130 Canal Street, Suite 603, Pooler, Georgia 31322, to release a copy of my patient records or x-rays containing protected health information to
Ultrasound Contraindications: An area of the body where a malignancy is known to be present An acute infection or sepsis Pregnancy Deep Vein thrombosis (DVT) Arterial Disease An anesthetized area or condition that causes impairment of sensation, such as chemotherapy Cardiac pacemaker A healing fracture Ischemic tissue in individuals with vascular disease where the blood supply would be compromised Any metal in the body I, _________________________________, have read the above statement and to the best of my knowledge do not have any of the above listed contraindications to the use of the electric stimulation and ultrasound equipment. ___________________________________________ _____________________________________ Signature Date Barnes Family Chiropractic 130 Canal St., Suite 603, Pooler, GA 31322 (912) 748-3755 Fax (912) 748-3031 Authorization to Release Patient Records I hereby authorize Barnes Family Chiropractic, 130 Canal Street, Suite 603, Pooler, Georgia 31322, to release a copy of my patient records or x-rays containing protected health information to