Human Treatment Consent Form

Name*

First NameLast Name

Contact Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

Town/ City

Postal Code

Birth Assigned Gender

MaleFemale

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Name

First NameLast Name

Practice Address

Street Address

Street Address Line 2

Town/ CityCounty

Postal Code

Are you on any medication?

Do you have any contraindications/precautions for treatment that you are aware of?

Reason for treatment intervention

Details about your condition/ current issue

Preferred Method of Contact*

PhoneEmail

I would like to sign up to the client newsletter and understand I can choose to opt out at any time:

YesNo

By completing this referral you agree to Animal Rehab Partners' terms & conditions.

Payment is required on the day of treatment, late payment will incur a fee. Services cancelled with less than 24 hours notice will incur a late cancellation fee.
Be advised that for a sports massage treatment you may be required to be in underwear; you will be draped to ensure modesty and at no time will genitalia or breast tissue be exposed.
Ensure you wear loose fitting clothes and a normal bra.
I understand that my therapist or I may end the session at any time for any reason
It is the client's responsibility to provide a safe, comfortable and private location for the treatment to take place.
Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law
I understand that Rebecca Wyatt works in the capacity of a Chartered Physiotherapist, whilst Claire Johnston works in the capacity of a Human Sports Massage Therapist.

Date

Signature

Human Physiotherapy/Sports Massage Consent Form