Consent Form

Please fill out the following form.

First name

Last name

Date of birth

Day

Month

Year

Please indicate your preference for gluteal (buttock) treatment.

Yes (Direct contact)

Yes (Indirect contact - pressure applied through towel)

No (I do not consent to gluteal treatment)

Do you prefer a quiet, no-talking session?

Yes

I don't mind

Additional information, medical conditions, or comments

I confirm the information I have provided is accurate and I will inform my therapist of any changes. I understand treatment may involve assessment, manual therapy, physical contact and removal of clothing where necessary, with appropriate draping and only the area being treated exposed. I understand there may be temporary post-treatment effects such as soreness or bruising. I consent to treatment within the therapist’s scope of practice and may withdraw consent at any time.