Personal Details

Name

DOB

Contact Number

Contact email

Address

Occupation

Sports / Hobbies / Interests

Emergency Contact Name

Emergency Contact Number

Medical Details

GP Surgery

GP Surgery Contact Number

Please tick the box if 'YES' to any of the following
Do you have a history of hert disease or chest pain??Do you often feel faint or have spells of severe dizziness?Do you have hypertension (high blood pressure)?Do you have diabetes?Do you have a pacemaker?Do you have oteopenia orosteoporosis?Do you have eplilepsy/seizures?Do you have asthma or other respiratory conditions?Do you have any allergies/sensitivities to tape, creams, cold etc?Are you pregnant?Do you smoke?Have you ever had or do you presently have cancer?Have you ever had major surgeries or serious illnesses?Are you taking any medications?Do you have any bleeding disorders?

Any Other relevant information (e.g. current medications / current or previous injuries)

Consent
I consent for my therapist to treat me with Sports Massage Therapy, including any recommended physical assessments, examinations and massage techniques. I acknowledge and understand that the therapist must be fully aware of any existing medical conditions. I have provided a detailed medical history and will notify my therapist of any changes. I do not expect the therapist to have foreseen any previous or pre-existing condition that I have not mentioned. I understand that the massage therapist is providing massage therapy services within their scope of practise and am aware that the therapist does not diagnose illnesses, prescribe medications nor physically manipulate the spine or its immediate articulations. I understand that massage may provide benefits for certain conditions, but results are not guaranteed. I also understand that massage therapy may produce side effects which will be discussed with me in full prior to the start of my physical assessment.
The therapist will discuss all treatment procedures with me and I understand that I have the right to question massage techniques used and to receive an explanation of any massage techniques performed during the treatment. I will tell the therapist about any discomfort I may experience during the session and understand that the treatment will be adjusted accordingly. I understand that at any time I can withdraw my consent and that treatment will be stopped. I understand if I do not turn up for my appointment or fail to give to give a minimum of 24 hours notice to change or cancel my appointment the full cost of the treatment will be payable.

I accept the above conditions