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This is a massage treatment and is not a medical or allied health treatment (physiotherapy,
osteopathy, chiropractic)
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I have viewed the therapists’ qualifications
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The risks specific to my individual circumstances may have a bearing on my decision to proceed with
he proposed treatment
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The therapist reviewed my health history before treatment commenced
-
The therapist explained that the physical assessment I received may involve partial undressing and
may require the therapist to palpate (touch) the area(s) of my body relevant to my presenting
condition
-
The therapist explained the treatment options to me and has given me choice
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The therapist explained the associated risk and possible side effects with the treatment options as
described
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The therapist discussed the massage procedures, the areas of the body to be treated, the undressing
and dressing procedures, the draping procedures and the positioning on the table for and during
treatment
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The therapist established that the treatment session will be stopped should the treatment as first
agreed to, require modification. The therapist will explain the reason for the change and any risks
and/or side effects as a result of the change
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I can ask any questions in regard to any modification to the treatment plan. I should be totally
comfortable with the explanation and reasoning for the change before consenting to the modification
to the initial treatment plan
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The therapist has explained that I have the right to refuse treatment, to make changes to the
reatment and to stop the massage at any timet
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I have the right to request evidence for treatment that may include the abdomen, anterior and lateral
chest, and buttock and / or groin areas. I understand I have the right to refuse treatment of these
areas
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If I agree to treatment to any of the areas mentioned in the point above, I may be requested, by the
therapist, to complete a consent form relevant to those areas
