Health Consent Form
Please complete this form before your sports massage appointment. Your information helps ensure safe and effective treatment.
Full name
First Name
Last Name
Date of birth (DD/MM/YYYY)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email address
example@example.com
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment date (DD/MM/YYYY)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for massage / areas of pain or tension
When did this start?
Any recent injury?
Health screening – tick anything that applies
Heart / circulation condition or blood clot
Recent surgery, injury or fracture
Diabetes, epilepsy or osteoporosis
Cancer or current cancer treatment
Fever, infection, rash or open wound
Pregnant or recently given birth
None of the above
Details of ticks / other conditions relevant to massage
Current medicines / allergies (including oils, lotions or latex); write 'none' if applicable
Electronic signature - type your full name
First Name
Last Name
Date (DD/MM/YYYY)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: