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Massage Patient Consent Form

Book an Appointment
Massage Consent Form
Name
(dd/mm/yyyy)
Address
Email Consent
Payment Method - Please confirm
I understand that payment is expected at each treatment. I understand that I may be charged for missed appointments or appointments cancelled at late notice (less than 24 hours)
Clear Signature
Signature required
Medical Checklist.
We ask these questions for your safety. Please contact us or ask at your appointment if you have any queries or are uncertain.
Pre-existing medical conditions
Have you had any of the above? If Yes, please select.
Female Patient Only
Are you Pregnant?
Clear Signature
Please Sign

Please note that your are welcome to be accompanied during your treatment and that all under 16 year olds must be accompanied.

16-18 year olds must be accompanied to the clinic for their first appointment.

For further information on each of our therapists, the conditions we treat and other services we provide, please see our websites:

www.ashbournephysio.co.uk www.hiltonphysio.co.uk

Please check that all your information is correct before submitting.