Consent Form – EosBody

Please provide any relevant details of your health and injury history that may affect your treatment, prior to your first booking. For subsequent appointments, please inform your Practitioner if there are any changes or amendments to this information is always up to date. This will help us to tailor your treatment to your current needs, avoid unnecessary or ineffective interventions and help you perform at your best.

Health History and Consent

Name *

First name

Surname *

Last name

Date of Birth *

Address *

Postcode

Email *

Contact Phone *

Emergency Contact: Name *

Emergency Contact: Phone *

GP Surgery

Consent for Emergency Medical Attention *

Yes, I give consent for emergency medical attention. In the event of accident or illness, when it is not possible to communicate with me, I give permission for the Practitioner to arrange for necessary transport and/or medical attention for me. I understand that I will be responsible for any expenses incurred.

Occupation / Physical work demands

Regular physical activities / Sports / Exercise

Please give details of any pre-existing conditions that may affect your massage treatment *(i)

Human Body

Do you have any current symptoms of pain, discomfort or injury?

How long have you been experiencing this?

Have you received any prior medical advice or treatment for this injury or condition? If yes, how long ago? Are you under the care of any other specialists?

Oil is usually used on the skin during the treatment (usually ALMOND oil).

I'm fine with ALMOND OIL

Please indicate if you would prefer an alternative (i.e. own moisturiser, aqueous cream):

Complementary Therapy - Disclaimer *(ii) *

I understand that massage is a complementary therapy and my Practitioner cannot give medical advice. To the best of my knowledge I have disclosed any pre-existing conditions or other information which may affect my massage treatment.

Covid-19 Special Conditions *(iii) *

I agree to inform the Practitioner and cancel/postpone my appointment if I develop any symptoms of covid-19 within the 14 days prior to my appointment. I agree to inform my Practitioner if I test positive for covid-19 within 14 days after my appointment. I consent to my details being used for the purpose of contact tracing for covid-19 mitigation by the relevant health authorities.

*i. Contraindications and Pre-Existing Conditions

You should seek medical advice for any pre-existing conditions that may be affected by massage treatment prior to booking including:

Immunological (allergies, Aids/HIV, cancer, CFS/ME, autoimmune disease )
Cardiovascular conditions (e.g. high/low blood pressure, heart attack, diabetes, stroke, varicose veins, fluid retention/oedema, haemophilia, phlebitis, thrombosis, inflammatory conditions, cold hands/feet)
Respiratory conditions (e.g. asthma, bronchitis, pneumonia, pleurisy)
Musculoskeletal conditions or prior injuries (e.g. accidental injury, recent surgery, scarring, wounds, broken skin, bruising, fractures, disc injury, ligament or muscular injury, whiplash, hernia, metal plates or pins, arthritis, osteoporosis, cartilage injury)
Neurological conditions (e.g. trapped nerves, inflamed nerve, motor neurone disease, multiple sclerosis, epilepsy, Parkinson’s disease, tension headaches)
Psychological conditions (e.g. stress, anxiety, depression)
Sleep disturbance (e.g. insomnia, daytime sleepiness)
Pregnancy

This is not an exhaustive list and you should seek expert medical guidance if you have any concerns.

*ii. Effects of Massage

Massage is a complementary therapy. During and after massage treatment, most people experience:

relaxation
release of muscular tension
increased energy
sense of well-being

Some people experience

dehydration
feeling tired
disorientation
delayed muscular stiffness
temporary nausea.

If possible, avoid eating a heavy meal up to two hours prior to your treatment. Please advise the Practitioner if you feel discomfort, for any reason, during the treatment.

*iii. Covid-19 Special Conditions

Cancellation fees will not be charged if you need to cancel or postpone your appointment due to exposure or potential exposure to the SARS-COV-2 coronavirus, or symptoms of Covid-19.

If you experience any symptoms of Covid-19 within 14 days before your appointment please let us know immediately so we can change your appointment. If you experience symptoms within 14 days after your appointment, please let us know so we can take any necessary steps for testing, isolation or contact tracing.

Please seek medical advice as soon as possible and follow latest health authority updates regarding symptoms, treatment and isolation or quarantine procedures.

We look forward to welcoming you back once you are healthy and well and we value your contribution to public health by following best practice mitigation measures.