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Consent Form

Please fill out the following form, 24 hours prior to your treatment. (please complete, after you made a booking)

Date of birth
Day
Month
Year
Do you have any spinal issues (e.g., herniated disc, lumbago)?
No
Yes

If the answer is YES, the use of the massage bed’s back roller function is not recommended and should only be done at my own risk.

Are you pregnant?
No
Yes

If the answer is YES, the use of the massage bed is not recommended during pregnancy. Please also be aware that some of our longer treatments may cause discomfort during pregnancy. If you choose to proceed, you do so at your own risk.

Do you have any allergies?
No
Yes
Are your ears sensitive?
No
Yes
Do you have any skin conditions?
No
Yes
Have you ever had an epileptic seizure?
No
Yes
Do you have a pacemaker?
No
Yes
Have you ever experienced a panic attack?
No
Yes
Do you take any blood thinners or have any blood clotting disorders?
No
Yes

If the answer is YES, the massage function of the massage bed may only be used at my own risk.

Do you have any vascular disorders?
No
Yes

If the answer is YES, the massage function of the massage bed may only be used at my own risk.

Do you have high blood pressure?
No
Yes

If the answer is YES, the massage function of the massage bed may only be used at my own risk.

Are you currently undergoing corticosteroid treatment? (This may thin the skin and make the blood vessels more fragile.)
No
Yes

If the answer is YES, the massage function of the massage bed may only be used at my own risk.

Do you have osteoporosis?
No
Yes

If the answer is YES, the massage function of the massage bed may only be used at my own risk.

Are you currently undergoing chemotherapy? (In this case, we recommend only the lowest intensity setting or switching off the massage function, as it may be contraindicated.)
No
Yes
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