Consultation Consent Form
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Province
Postal
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Fredrick@gmail.com
Sex
*
Female
Male
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Sports activity
Current Activity in Sports Levels
Active
Inactive
Do you plan on doing any activities after the session
yes
no
Terms and conditions
Contraindications (Please tick where appropriate) Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.
Pregnancy
Cardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)
Haemophilia
Any condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, Coach
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Asthma
Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease)
Bells Palsy
Trapped/Pinched nerve (e.g. sciatica)
Inflamed nerve
Cancer or previous cancer
Postural deformities
Dysfunctions of the nervous systems (e.g. cerebral palsy/sroke/ Multiple sclerosis
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
blood thinners
DVT
Contraindications that restrict treatment (Please tick where appropriate)
Fever
Contagious or infectious disease
Under the influence of recreational drugs and/or alcohol
Diarrhea or vomiting
Skin diseases
Undiagnosed lumps or swellings
Localised Swelling
Pregnancy (abdomen)
Varicose veins
Cuts
Bruises
Abraisons
Scar tissues (2 years for major operation and 6 months for a small scar)
Sunburn
Hormonal implants
Abdomen (first few days of menstruation depending how the client feels)
Haematoma
Hemia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
Circulation problems (Please tick where appropriate)
Heart
Blood pressure
Fluid retention
Varicose Veins
Cellulite
Kidney problems
List any Antibiotics/Medication if taking
List any allergies or allergic reaction to products
Disclaimer Form
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.
Client Information
*
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 here by indemnify the therapist (Ethan Conroy) against any adverse reaction sustained as a result of the treatment.
The patient consents to treatment that has been explained and that any side effects to treatment and (Ethan Conroy) isn't liable for any cuts or bruises or soreness and these are deemed normal for treatment.
*
I here by indemnify the therapist (Ethan Conroy) against any adverse reaction sustained as a result of the treatment.
Photography and video
Patient consents to being photographed and videoed throughout treatment if the therapist chooses to do so for social media purposes only.
I consent
I do not consent
Treatment
Treatment
£25.00 (1 hour) Performance Sports Massage
£25.00 (30 minutes) Compression Recovery Boots Session
£40.00 (90 minutes) Elite Athlete Recovery - Includes Massage, Myofacial Cupping and Compression Recovery Boots
(Add Cupping to the session for extra £10)
Signature of consent
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Parental Consent (Where Applicable)
To be completed by Parent or Guardian if client is under the age of 18.
By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) and consenting to the treatment recommended by the therapist. We also request that you or an appropriate adult remain in the treatment room to supervise all interactions between the therapist and the minor.You also agree that you have completed the Consultation Form and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).
I Agree
Parent/Guardians Full Name
Signature of consent
Signature
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
Should be Empty: