Sports Massage Consultation Form
Contact Telephone Number
Preferably Mobile Telephone
Client Email address
Date of Birth
Current Activity Levels
Written permission required by GP/Specialist (Separate form to be collected)
Please tick or answer where appropriate
List any medication your are currently takng - Plus any allergies, injuries, family history, illnesses and major ops here.
Present Condition / Injury
How many hours a day do you work at a computer?
Do you exercise? If so how many times per week?
Please read the following and tick the appropriate box, by ticking the box you are confirming you are in full agreement with the statements contents.
I confirm that I have understood the treatment that I am going to receive. I also confirm that I am willing to proceed without confirmation from my own G.P or Consultant.
I confirm that I have understood the treatment and given my medical history I would prefer to consult with my GP or Consultant prior to receiving the treatment.
You should note that if the therapist is unable to explain to you the contraindications or is unsure of anything that may apply to a specific condition then they should not treat you without asking you to consult with your GP or Consultant. It is your responsibility and not that of the therapist to consult your GP or Consultant.
I hereby indemnify the therapist (Becky Hadlington) against any adverse reaction sustained as a result of the treatment.
The first consultation will be longer to do a full postural assement before any treatment is carried out. Therefore the time of massage / treatment may be shorter on your first session.
Client Full Name
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