Treatment Consent Form

Details

Contact

Phone

Date of Birth

Activity

Level of Activity

LowModerateHigh
 

Sport

Contacts

Doctor

Emergency Contact

How did you find us?

In order to better serve you, please provide us with the information below

Part1: Relative Information

1. Are you at least 18 years of age? (Clients under the age of 18 cannot receive treatment without parental consent.)

YesNo
 

2. Do you have any problems that would be adversely affected by heat, percussion, or deep massage?

YesNo

 

3. Are you pregnant?

YesNo

 

4. Do you have a history with any of the following?

StressAllergiesContagious diseaseDiabetesWear contact lensesBack painDepressionCancerCardiac/circulatory problemsArthritisFrequent headachesSensitive to touch or pressureOsteoporosisEpilepsy or seizuresBruise easilyJoint swellingVaricose veins

If you marked yes for any of the above are you released by your physician to receive treatments?

YesNo
 

5. Are you currently taking any prescription drugs, blood thinners (Aspirin), pain relievers, or supplements?

YesNo

 

6. Do you have any other relevant medical concerns not listed above?

Part 2: Symptoms / Current Problem / Injury

1. Do you have a particular injury/problem needing treatment at the moment?

2. When and How did this happen?

3. Have you had any previous treatments for this same problem?

4. List any other previous injury you have had

I understand that the treatment I receive is provided for the basic purpose and relief of an injury. If I experience any discomfort during the session, I will immediately inform the therapist of my discomfort. I further understand that treatment should not be construed as a substitute for medical examination. I understand that the therapist is not qualified to diagnose, prescribe, or treat any mental illness, and that nothing said in the course of the session given should be construted as such, because the treatment should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile during today’s and all future sessions, and understand that there shall be no liability on the therapist's part should I fail to do so. I am aware that the therapist is a sole trader. I also understand that the license therapist reserves the right to refuse to perform treatment on anyone whom he/she deems to have a condition for which the treatments they use are contraindicated.

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