Ele King Therapy Room Client form

Date

First Name Last Name

Pregnant Breastfeeding None of the above

Pacemaker Electrical implant None of the above

Fainted Seizure None of the above

Asthma Bronchitus Shortness of breath Migraines None of the above

A damaged heart valve Risk of any type of infection None of the above

Fractures Tendon issues Ligament or cartilage damage None of the above

Diabetic Impaired wound healing None of the above

Dry Needling / Massage cupping / Dry Cupping

If the therapist feels it necessary during the treatment, are you happy to have some or all of the above done? if you do not know what is involved please ask for an explanation of each and only sign once this has been explained.

Yes i know what these treatments are No i don't know what they are

Hijama (wet cupping)
ONLY ANSWER IF THIS IS THE TREATMENT YOU ARE BOOKED IN FOR

(if you are mildly anaemic please note you must confirm to your therapist that you are taking your prescribed tablets for 2 weeks prior to treatment

Declaration:

To the best of my knowledge I confirm that all the answers I have given are correct and truthful. That my mental and physical health and fitness is good that if there is any change in my condition between treatments `i will tell the therapist. I confirm I am happy for the therapist to carry out the treatment on me: