Consent to Treatment

Last name: ..................NGUYEN.......................First name: ..................NGOC MUI....................

Date of birth: .........2003............ year........08.......... month......16......... day
Phone number:…………..........+36206228377.......................................
E-mail /please fill out exactly/: ............nguyenngocmui16082003@gmail.com..................................
Address in Hungary: .............................Dankó utca 11.,1086. Budapest.........................
SH Application ID…………………2022_553293………………………
If you have Social Security Number /TAJ/ or Passport number: ..............C9910634...............

Which of our services are you using?

☐ X-Ray
☐ Medical Examination
☐ PCR test
☐ Blood tests /HIV ag, HCV ab, HBsAg, HBc Ab, TBC quantiferon/

Please write your special request befor medical examinatoins:

………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

Do you have Drug intolerance:

……………No……………………………………………………………………………

Any other illness:

…… No…….…………………………………………………….........
(abdomen pain, enteritis, bilious attack, distention, diarrhea, constipation, frequent urinary
tract infection, prostatitis, vaginal inflammation, lactose intorelance, allergy, hay fever,
asthma, abortion, Assisted Reproductive Technology, epidural anesthesia, epilepsy, heart
attack, adenoids,  transient ischemic attack (TIA), aneurysm, calculus, pancreatitis,
nephrosis, diverticulum, myoma, cysta, implant, prothesis, screw, pacemaker, shunt,
electric drug dispenser)

Hypertension: no □, yes □…....../…....Hgmm, medications □ ........................

Osteoporosis: no □, yes □ Lumbalis □ hip □ ........................................................
Diabetes: no □, yes □ I./II. type, since……..........(year), medication □ insulin □
Migraine/Headache: no □, yes □ ………… times / month, since ....................(year)
Vascular problems: no □, yes □ varicose veins/ anticoagulant / thrombosis /.................
Prothesis: no □, yes □ in:................................................................................
Surgeries: no □, yes □ /nasal septum, spinal hernia, tonsil, appendix, gall, kidney,
heart, thyroid, bubonocele, gynecological, varicose veins, hemorrhoids/
Other: ………………………………………………...........................................
Fracture, injury: shoulder, upper arm, forearm, wrist, leg, ankle, collarbone, neck,
concussion
Other: ……………………………………………………………………...........
You are aware of your current pregnancy: no □, yes □

I undertake to comply with the guidelines set out in the treatment program and cooperate fully with
management staff for the sake of my health.
During the treatment of locomotor disorders, temporary transient symptoms may initially occur. This is
mostly a sign of your body responding to treatment. Please let us know if your symptoms will not be
relieved over time.
If you do not participate in the proposed medical examination, our professionals cannot be held
responsible for any resulting injuries or health problems.
Please understand that the treatment can only be held within the booked time. If you cannot
participate, please cancel your appointment 24 hours before, otherwise it might be billed to you.

I confirm that the information given in this form is true, complete and accurate, and I do not know about
any other health risk that might influence the effectiveness of the therapy.
I agree that my test results (MRI, Xray, etc.) and any correspodence related to my treatment is to be used
by the Medical Point in and KKM its own database only.
I accept the financial implications of the services provided by the Health Center.

As a parent or guardian of patient named on first page, I grant my authorization to Medical Point and its
medical representatives to treat my child as previously discussed.

Budapest, 2023/03/23................

....................Nguyen Ngoc Mui...............

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