Aura Consent Forms

Personal / Contact Details

Name

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Date of Birth (dd/mm/yyyy)

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Email Address

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Phone Number

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Postcode

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Address

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Therapist

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If you have any of the contraindications listed below you will be unable to receive a massage treatment. Please check if you have any of the following.
Fever/Flu	Yes No	Contagious Diseases	Yes No
Under the Influence of Alcohol or Drugs (including medicated pain relief)	Yes No	Recent Operations Or Acute Injuries	Yes No
Skin Diseases	Yes No	Neuritis	Yes No

The therapist can massage, but not over any areas affected by: (Please check if you have any of the following).
Varicose Veins	Yes No	Undiagnosed Lumps and Bumps	Yes No
Bruising Cuts Abrasions	Yes No	Recent Scar Tissue	Yes No
Allergies	Yes No	Sunburn	Yes No
Undiagnosed Pain	Yes No	Inflammation Including Arthritis	Yes No

If you suffer from any of the following conditions, massage can only take place once it has been approved before your session in writing by your Physician. (Please check if you have any of the following).
High/Low Blood Pressure	Yes No	Cardio vascular conditions (thrombosis, phlebitis, hypertension, heart conditions)	Yes No
Oedema	Yes No	Psoriasis	Yes No
Eczema	Yes No	Dermatitis	Yes No
Impetigo	Yes No	Osteoporosis	Yes No
Curvature of the spine	Yes No	Sciatica	Yes No
Scoliosis	Yes No	Compressed Disks	Yes No
Nervous Condition	Yes No	Psychotic Condition	Yes No
Heart conditions	Yes No	Angina	Yes No
Pacemaker	Yes No	Epilepsy	Yes No
Diabetes	Yes No	Bell's Palsy, Trappe d or Pinched Nerves	Yes No
Gynaecologic alnfections	Yes No	Contraceptive Implant	Yes No
Any condition already being treated by a medical practitioner?	Yes No	Pregnancy (If so how many weeks?)	Yes No

Consent Form: Disclaimer

I understand that, after having the massage treatment, I could possibly see bruises post treatment as this often occurs due to the pressure asked for. However, I am prepared to take full responsibility with this disclaimer and will not pursue any action against the therapist or salon should there be any reaction what so ever. No refunds will be given.

Please accept Disclaimer.

Massage Consultation Form

Personal / Contact Details