Booking Form Let’s work it out Individual care to each client Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Brief Description your principle concern Have you been diagnosed with low bone density, osteoporosis or arthritis? If so please specify. Are you currently pregnant? Yes No Any known allergies Do you have any known skin conditions, if yes, please specify I understand that Áine Barron is currently undertaking her Master's Degree in Physiotherapy and is covered by Balens Europe to engage in sports massage and exercise rehabilitation as a Student Physiotherapist and cannot work outside of her scope of practice (basic massage and exercise prescription) taking all measures to prioritise patient safety. I understand that a sports massage involves the manipulation of muscles and soft tissues to relieve tension, improve circulation and assist in the recovery of muscle and joint function. I understand that Áine Barron may prescribe exercises that Rossa Keane will include in my sessions to aid in my recovery and performance. I understand that massage may cause soreness or discomfort in the treated area (subsiding within ~48hrs), localised bruising or swelling, temporary changes in flexibility or muscle tightness alongside the aggravation of the present concern/injury. If pain persists or abnormal swelling and or bruising occurs, I understand I must contact a medical professional and ensure either Rossa Keane or Áine Barron is aware of this. I understand that if necessary, Áine Barron may refuse treatment and recommend I see a fully qualified medical professional if she deems my concern to be outside of her scope of practice. I understand that at any point throughout the treatment I can stop if I feel uncomfortable. * Yes No I have been given an opportunity to ask questions as to the procedures. I have read this form and fully understand its terms. I understand the nature of this treatment and any potential side effects. I understand Áine Barron is a Student Physiotherapist taking every step necessary to ensure client safety. I understand I can withdraw my consent for treatment at any point during the treatment. I send this form freely and voluntarily, without inducement. Thank you!
