TREATMENT FORM

The following information is required for your safety and health. These details will be treated in the strictest confidence. It may, however, be necessary for you to consult your GP before any treatment can be given.

First name

Last name

Birthday

Day

Month

Year

Phone

Occupation

MEDICAL HISTORY & DETAILS

Do you, or have you ever, had any medical or health issues?

Are you on any medication? If so, what?

Do you have any allergies? If so, what?

Do you have any previous injuries

Current condition / reason for treatment?

Pain rating (1-10 with 10 highest)

I confirm that I have disclosed all known medical conditions and answered all questions honestly. I will update the therapist on any changes to my medical profile and understand that the therapist is not liable if I fail to do so. I agree to hold the therapist and their agents harmless from any claims or liabilities related to injury, directly or indirectly resulting from their services.

Signature

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