Massage Forms

First name

Last name

Phone

I agree to be contacted by phone and email.

Other conditions not listed above:

Current medications (including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies):

Recent surgeries and dates of surgery

Current symptoms: (location and duration or onset)

History of presenting complaint: (how it happened - position / direction etc)

Behaviour of and type of pain: (constant / with movement / with activity / sharp / shooting / dull / aching etc)

Aggravating factors: (activities / posture / stressors)

Relieving factors: (movement/rest/posture/heat/cold)

Previous Treatments: (include all health care types – Complementary Medicine Practitioner and / or Medical Doctor, Physiotherapist, Osteopath, Chiropractor, Dentist):

Results:

This clinic may use a variety of Therapeutic, Remedial or Myotherapy modalities in your treatment.

There is always some risk associated with any health treatment. The best way to reduce the chance of risk occurring is to answer all the questions about your health, fully and honestly, before treatment begins. The therapist will explain the treatment strategy to you before they commence and outline any associated risks in relation to your condition. If you do not understand, or if you have specific questions, it is important that you ask for further explanation.

Below is a list of potential risks associated with therapies listed:

Some essential oils may interact with alcohol, medications and may irritate or photo‐sensitise skin, cause blood thinning or euphoria and may negate homeopathic remedies. Not recommended for infants, pregnancy, breast feeding or heart & kidney problems.
It is possible that your condition could be aggravated. With a full medical history, therapists will be able to adjust treatment procedures to minimize aggravation of any existing conditions.
Tell the therapist if you bruise easily, have a bleeding disorder or are taking blood thinners. Cupping typically leaves marks which are usually painless and can last over a week.
Advise the therapist if you have sensitive skin and tell the therapist if the heat becomes unbearable.
Advise the therapist if you have low blood pressure (hypotension). Do not skip a meal before treatment. Get up slowly after the treatment. Keep well hydrated with water.
It is possible to develop infection of the hair follicles (folliculitis) from friction or whenever the skin is punctured. Advise your therapist if you have a known skin condition(s) and/or immune problems.
Some medications can affect your skin and immune system. Myotherapy fine filament needles are pre–sterilized, single use disposable needles
A pain response can be stimulated on the skin by pricking, burning, crushing or freezing. Tell your therapist if you are sensitive to such stimuli, and if you become uncomfortable or experience pain during treatment. A massage or myotherapy treatment should never cause unbearable pain.
With pregnancy obtain written medical clearance from your treating medical practitioner. Ask your massage therapist if they have had advanced training in pregnancy massage. Declare all medical conditions and state if you have any problems carrying. Go to your treating medical practitioner if you feel unwell after the massage.
It is common to feel relaxed or sleepy after treatment so avoid getting up quickly from the treatment table and give yourself time to adjust after treatment before driving or using stairs.
Avoid driving immediately after the treatment if you feel sleepy. Keep well hydrated with water.

I understand that:

This is a massage treatment and is not a medical or allied health treatment (physiotherapy, osteopathy, chiropractic)

I have viewed the therapists’ qualifications
The risks specific to my individual circumstances may have a bearing on my decision to proceed with the proposed treatment
The therapist reviewed my health history before treatment commenced
The therapist explained that the physical assessment I received may involve partial undressing and may require the therapist to palpate (touch) the area(s) of my body relevant to my presenting condition
The therapist explained the treatment options to me and has given me choice
The therapist explained the associated risk and possible side effects with the treatment options as described
The therapist discussed the massage procedures, the areas of the body to be treated, the undressing and dressing procedures, the draping procedures and the positioning on the table for and during treatment
The therapist established that the treatment session will be stopped should the treatment as first agreed to, require modification. The therapist will explain the reason for the change and any risks and/or side effects as a result of the change
I can ask any questions in regard to any modification to the treatment plan. I should be totally comfortable with the explanation and reasoning for the change before consenting to the modification to the initial treatment plan
The therapist has explained that I have the right to refuse treatment, to make changes to the treatment and to stop the massage at any time
I have the right to request evidence for treatment that may include the abdomen, anterior and lateral chest, and buttock and / or groin areas. I understand I have the right to refuse treatment of these areas
If I agree to treatment to any of the areas mentioned in the point above, I may be requested, by the therapist, to complete a consent form relevant to those areas

I agree to for the therapist to use Heidi Help - a note transcribing AI.

I agree to the terms & conditions and give consent for my treatment.

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