This form is to be completed once you have booked a Sports Massage Therapy appointment with the Bloomsbury Fitness reception team, and must be completed a minimum of 24 hours before your scheduled appointment.

Please ensure you have read the Sports Massage Client Agreement, and by submitting this form, you commit to the terms as specified in the aforementioned document.

Only authorised staff members will be able to review submissions of this form, and data will be stored in line with GDPR regulations.

  • About you
  • Please indicate whether you currently have, or have ever had, any of the following:
  • Declarations
  • Complete
Required field

About you

Please indicate whether you currently have, or have ever had, any of the following:

Please comment if any immediate family members have these issues too.

Skin conditions e.g. eczema or psoriasis.
Diabetes
Epilepsy
Heart problems e.g. angina.
A pacemaker.
Circulatory problems e.g. high or low blood pressure.
Steroids
A current problem or history of cancer
Significant surgeries requiring general anaesthetic
Treatments such as deep x-ray or chemotherapy.
Chest or breathing problems.
Anticoagulation medications e.g. Warfarin.
Sudden weight loss.
Osteoporosis.
Recent fractures or trauma.
Recent x-rays or scans.
Rheumatoid arthritis.
A family history of arthritis.
Thrombosis or phlebitis.
Bell’s palsy, or trapped or pinched nerves.
Neuritis.
Pregnancy.

Declarations

If I replied ‘yes’ to any of the questions in the previous section, I must obtain the advice and consent of a doctor before attending a sports massage session and bring along any required medications etc.

If a doctor does not think a sports massage is suitable given my condition, I will not be allowed to attend the session, but can contact the Bloomsbury Fitness reception team for a refund.

  • My sports massage therapist is providing massage therapy services within their scope of practice, as defined by their qualifications and professional body. I understand that sports massage therapy is a manual form of treatment, and it is possible that I will experience some side effects. The most common side effects, though not experienced by everyone, are some discomfort or soreness after treatment, a headache or bruising, usually for about 24 to 48 hours after treatment.
  • The therapist is not a clinician and does not diagnose illness, disease or any other medical condition. I understand that massage therapy, including any physical assessments or examinations performed, are not medical examinations and are only performed to better inform the most appropriate sports massage treatments for me.
  • No assurance or guarantee has been provided to me as to the results of the treatment and I understand that any treatment performed has an element of risk associated with it, including the possibility of injury and death. By signing this form, I assume these risks wilfully.
  • At the beginning of my session, before the treatment begins, I will have the opportunity to explain my condition to the therapist and ask any questions I have.
  • I may withdraw my consent at any time during the session and treatment will be stopped.
  • The appointment will not go ahead if I am contagiously ill or any of the above conditions have changed on the day of the session.
I consent to receiving treatment of sports massage therapy including physical assessments and massage techniques, and have read the TeamUCL and Bloomsbury Fitness Sports Massage Client Agreement.
Sign above