Asirilanka Therapy Dashboard!

View Quote Request Clients

Please fill out all of the below questions, prior to your appointment.

Full Name *

Email Address *

Treatment Type *

Client Address *

Telephone No *

Occupation *

Sex *

Date of Birth *

GP Address

Contraindications (please tick where appropriate).

Never treat unless the injury has been diagnosed and treatment has been recommedned by a medical practitioner.

Slipped Disc,Taking prescribed medication

Contraindications that restrict treatment (please tick where appropriate)

Varicose Veins

Written permission required by GP/Specialist (Seperate form to be collected) *

Personal Information

Please tick or answer where appropriate

Muscular / Skeletal Problems:

Back

Digestive Problems:

Back

Circulation:

Varicose Veins,Cellulite

Nervous System:

Stress

List any antibiotics / medication you are taking:

List any herbal remedies you are taking:

How many hours a week do you spend working on a computer?

Please list any allergies including any skin allergies that could be caused by massage oil, cream or wax:

Do you exercise? How many times a week?

Right or Left Handed? *

Sports Details

Please tick or answer where appropriate.

What sports / activities do you participate in?

How long have you been doing these?

At what level do you participate?

How many days a week do you train in these?

What is your preffered position / discipline / distance within your sport?

Please list any injuries sustained whilst participating in your sport or activity

DISCLAIMER

Client Information:

I confirm that I have understood the treatment that I am going to receive. I also confirm that I am willing to proceed without confirmation from my own G.P or Consultant.
YES
I consent to full treatment by Asirilanka Sports Massage Therapy which can include any of the following: Joint adjustment or manipulation or mobilisation to the joints of my spine (neck and back), pelvis and extremities (shoulder, upper limbs and lower limbs), Cupping Therapy, IASTM Therapy, The use of a hand held Massage Gun and Full body Sports Massage Therapy. This consent applies to all my present and future treatments at Asirilanka Sports Massage
YES
I hereby indemnify the therapist (Asirilanka Therapy) against any adverse reaction sustained as a result of the treatment.
YES
Please tick this box if you are happy for any photographic or video content pre, during or post treatment to be shared and used for promotional purposes

you are in full agreement with the statements contents.
Client Information:
You should note that if the therapist is unable to explain to you the contraindications or is unsure of anything that may apply to a specific condition then they should not treat you without asking you to consult with your GP or Consultant. It is your responsibility and not that of the therapist to consult your GP or Consultant. *

Please type your name as part of your consent for the above consultation form:*

Please type todays date as part of your consent for the above consultation form:*

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