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Client Consultation Questionnaire

1. Personal Information

Please fill out the following form
in order to participate in our treatment services

Have you, or do you currently suffer with any of the following?

2. Subjective Assessment

Primary reason for booking? (select all that apply)

3. Informed Consent

I understand that the therapist is providing therapy services within their scope of practice as defined by The Society of Biomechanics in Sports and The Sports Therapy Association as part of the learning practice leading towards formal qualification. I hereby consent for my therapist to treat me with massage therapy for the above noted purposes
including such assessments, examinations, and techniques, which may be recommended, by my therapist. I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that therapy is not a substitute for a medical examination.
I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided and disclosed to the therapist all of those medical conditions affecting me. The information I have provided is true
and complete to the best of my knowledge.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.

Thanks for submitting!

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