Medical Consultation FormPlease complete the below Medical Consultation form prior to your first appointment at Relax Therapy. Name * First Name Last Name Your date of birth DD/MM/YYYY format Email * Tel number Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Doctor's Name * Doctor's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Sporting Activities Do you have, or have you had any of the conditions listed below in the past year/s * Pacemaker or pacemaker leads Heart Condition Cancer/Cancerous Legions Epilepsy Phlebititis or Thrombosis Varicose Veins Multiple Sclerosis Muscular Condition Inflammation, Infection or Tumour in any area Contact Dermatitis or any other skin disease Recent Scar Tissue Recent Operation Recent Illness Metal Implants, screws or prothesis Allergies Diabetes Allergy to rubber, copper or other metals Lack of normal skin sensation High/low blood pressure Any condition under medical care Are you pregnant? HIV Positive Hepatitis Are you taking any anti-depressants Are you taking any muscle relaxants None of the above If the answer to any of the above is yes, please provide further information I certify that the statements I have made are true and correct, and that I, having been advised and fully informed concerning the nature of the treatment process proposed to be administered, hereby authorise and direct you to administer such processes and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowledgement that (1) I have read, understood and fully agree to the foregoing consent. (2) The proposed treatment has been satisfactorily explained to me and I have all the information which I desire. (3) I hereby give my consent and authorisation voluntarily and release you and your agents of any claims that I have or may have in the future in connection with the described treatment. * First Name Last Name Today's Date Thank you!
