C O N F I D E N T I AL

CLIENT CONSENT FORM

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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.

Therapy

Outline of
possible risk

Strategies to minimize the possible risk

• Aromatherapy

Aromatic interaction
or
response

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.

• Any Therapy

Aggravation
of your condition

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.

• Massage
• Cupping
• Dry Needling

Bruising

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.

• Cupping
• Thermal

Burn

Advise the therapist if you have sensitive skin and tell the therapist if the heat becomes unbearable.

• Massage
• Myotherapy
• Aromatherapy

Fainting

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.

• Myotherapy
• Massage
• Dry Needling

Infection

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.

• Massage
• Myotherapy
• Cupping
• Thermal

Pain

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.

• Any Therapy

Pregnancy
complications

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.

• Massage
• Aromatherapy

Relaxed/Sleepy

Privacy Policy

It may be necessary to discuss your condition and/or treatment with your Medical Doctor or other referring practitioner.

Do you agree to allow discussions or information to be passed to, or between, health professionals for the purpose of improving your well-being?

You have the right to request a copy of a Privacy Policy from the therapist/clinic before proceeding with treatment.

Consent for Treatment ✓ please tick the applicable boxes once read I understand that:
✓ Please tick the boxes once read and sign and date the Consent

Client

Parent/Guardian

Therapist