Sports Massage Therapy - Informed Consent Form

Sports Massage Therapy - Informed Consent Form

EB Massage & Wellbeing
Name

First NameLast Name
DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Reason for booking your appointment:
Sports Massage Treatment - Procedure Explanation

Informed consent
I understand my sports massage treatment may include (please tick):
Sports Massage Treatment - Client Communication

Informed consent
I acknowledge (please tick):
Sports Massage Treatment - Explicit Consent
I understand and acknowledge (please tick):
Signature
Date

MonthDayYear
Date
Sports Massage Treatment - Ongoing Consent & Documentation
I understand that (please tick):
Contraindications checklist

Please tick where applicable to inform your therapist if you currently have, or have had in the past six months, any of the following symptoms/conditions:
Musculoskeletal issues
Please specify
Circulatory issues
Please specify
Neurological issues
Please specify
Skin issues
Please specify
Respiratory issues
Please specify
Immune issues
Please specify
Digestive issues
Please specify
Miscellaneous
Please specify
Have you been given permission by a medical professional to carry out this appointment?
Declaration:
I fully understand that thorough and honest responses to these questions are essential for my safety. I hereby confirm the information I have shared is accurate and I have disclosed all relevant medical conditions. I understand the safety and effectiveness of my treatment is reliant on honest communication and I understand its importance.
Client signature
Date

MonthDayYear
Date
Therapist signature
Date

MonthDayYear
Date
Should be Empty:

Sports Massage Therapy - Informed Consent Form

Sports Massage Treatment - Procedure Explanation

Sports Massage Treatment - Client Communication

Sports Massage Treatment - Explicit Consent

Sports Massage Treatment - Ongoing Consent & Documentation

Contraindications checklist

Declaration: