Scar Therapy Consultation & Consent Form

For scar therapy combining specialist scar work, myofascial release and Manual Lymphatic Drainage.

Emergency contact name

Emergency contact number

Medical History (Please tick everything that applies.)

Please provide details of any conditions selected

Current medication, supplements or injections

Allergies or sensitivities

Surgery, Injury & Scar History

Date of surgery or injury

Hospital, clinic or surgeon

Has your surgeon or clinician cleared you for scar therapy?

Has the wound fully closed?

Please describe the operation, injury or cause of the scar

Have there been any complications, infection, delayed healing, seroma or wound reopening?

Location of scar or scars

Approximate length or size

Please tick all features or symptoms that apply.

Current discomfort level, 0–10

How long have the symptoms been present?

Any loss of movement, posture changes or functional limitations?

Treatment Goals

Please tell us what you would most like to improve

Scar Therapy Consent

Scar therapy may include Manual Lymphatic Drainage, gentle scar mobilisation and myofascial release. Temporary redness, warmth, tenderness, tiredness, sensitivity or a short-term change in symptoms may occur. Treatment will not be performed over an open, infected or unhealed wound.

I confirm that the information provided is accurate and complete.

I agree to inform my therapist of any changes to my health, medication, wound or recovery.

I understand that results vary and no outcome can be guaranteed.

I understand treatment may be postponed and medical clearance requested if there are safety concerns.

I consent to Scar Therapy, Myofascial Release and Manual Lymphatic Drainage where appropriate.

Photo & GDPR Consent

I consent to photographs being taken for confidential treatment records. I consent to anonymised photographs being used for education or marketing. I do not consent to photographs being used for marketing. I consent to BOON securely storing my consultation and treatment records in line with UK GDPR.

Client full name as digital signature

Therapist Assessment & Treatment Record

Visual and palpation assessment

Scar mobility, sensation and restrictions

Treatment performed and areas treated

Techniques used: MLD, fascia release, scar mobilisation or other

Client response and any changes noted

Aftercare advice and recommended follow-up

Therapist name / signature

Working Hours

MONDAY - 09:30 AM – 07:00 PM
TUESDAY - 09:30 AM – 07:00 PM
WEDNESDAY - 09:30 AM – 07:00 PM
THURSDAY - 09:30 AM – 07:00 PM
FRIDAY - 09:30 AM – 07:00 PM
SATURDAY - 10:00 AM – 05:00 PM
SUNDAY - Closed

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