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Face Sculpt & Fascia Release
Face Lymphatic Drainage Massage
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Myofascial Release Therapy (Face & Upper Body)
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Home
Treatments
Skin Treatment
The Boon Method Signature Facial
Signature Holistic Skin Reset Facial
Nervous System Reset Facial
Advanced Skin Renewal (Microneedling)
Skin Smooth & Glow (Dermaplaning Facial)
Skin Resurfacing Peel (Chemical Peel)
Face Sculpt & Fascia Release
Face Lymphatic Drainage Massage
Signature Face, Neck & Head Healing Therapy
Massage Treatments
Lymphatic Drainage Massage (Body)
Myofascial Release Therapy (Face & Upper Body)
Head Healing & Nourishing Oil Therapy
About Us
Reviews
Blog
Contact us
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Fascia Release Consultation & Consent Form
Please complete this form before your appointment.
Client Details
Full name
Date of birth
Mobile number
Email address
Address
Emergency contact name
Emergency contact number
GP name and surgery
Medical History (Please tick everything that applies, even if it is well controlled.)
High blood pressure
Low blood pressure
Heart condition or heart failure
Diabetes
Kidney disease
Liver disease
Thyroid condition
Autoimmune or inflammatory condition
Cancer, current or previous
Blood clotting disorder or DVT
Taking blood-thinning medication
Epilepsy
Asthma
Pregnant or breastfeeding
Allergies
Recent illness, infection or fever
None of the above
Please give details of any conditions selected above
Current medication, supplements or injections
Allergies or sensitivities
Previous operations, hospital treatment or relevant medical history
Pain, Mobility and Fascia Assessment
Pain, Mobility and Fascia Assessment
Recent injury, sprain or strain
Recent fracture or dislocation
Osteoporosis or fragile bones
Disc problem or spinal condition
Joint replacement or metalwork
Hypermobility or connective tissue disorder
Fibromyalgia or chronic pain condition
Neurological symptoms, numbness or weakness
Varicose veins or vascular condition
Recent surgery
Easy bruising
Skin infection, open wound or rash
Headaches or migraines
TMJ or jaw tension
None of the above
Main area of tension, pain or restriction
Current discomfort level, 0–10
When did it begin and was there an injury or trigger?
What movements or activities aggravate or relieve it?
Previous diagnosis, scans, physiotherapy or other treatment
Treatment goals
Treatment Preferences and Boundaries
Face and jaw
Head and scalp
Neck and shoulders
Back
Chest
Abdomen
Hips and glutes
Arms
Legs
Feet
Other
Areas that must not be treated
Preferred pressure, positioning needs or touch sensitivities
Fascia Release Consent
Fascia release may involve sustained pressure, stretching and movement. Temporary tenderness, mild soreness, bruising, tiredness, headache or a short-term change in symptoms may occur. Treatment should never feel sharp, alarming or intolerable.
I confirm that the information I have provided is accurate and complete.
I agree to communicate discomfort and understand I may ask for pressure to be changed or treatment to stop at any time.
I understand fascia release is a complementary therapy and is not a substitute for medical diagnosis or treatment.
I consent to fascia release treatment.
Digital Signature and Treatment Record
Client full name as digital signature
Date
Therapist assessment and treatment plan
Areas treated, techniques and client response
Aftercare and follow-up recommendation
Therapist name / signature
Submit Details
