HB HEALTH

12 Beauchamp Place
Contraindications and Consent Form for London SW3 1NQ
CACI Quantum Tel: +44 (0)20 7838 0765
Fax: +44 (0)20 7838 0766

Please answer all the following questions:

Pacemaker? Yes/No
Pregnancy? Yes/No
Cancer? Yes/No
Epilepsy? Yes/No
Heart Conditions? Yes/No
Diabetes? Yes/No
Inflammation/Infections? Yes/No
Tumours? Yes/No
Varicose Veins? Yes/No
Recent Operations? Yes/No
Recent Scar Tissue? Yes/No
Allergy to rubber or metals? Yes/No
Lack of normal skin sensation? Yes/No
Thrombosis/Phlebitis? Yes/No
Retin A? Yes/No
Roaccutane? Yes/No
Metal implants/Screws? Yes/No
Prosthesis/Silicone? Yes/No
High Blood Pressure? Yes/No
Skin Diseases? Yes/No
Multiple Sclerosis? Yes/No
Botox/fillers? Yes/No
Anti-Depressants (except Prozac)? Yes/No

Name:----------------------------------------------------
Address:---------------------------------------------------------------------------------------------
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Tel.no.---------------------------------------------------------

List
Medications:----------------------------------------------------------------------------------------
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CONSENT AND AGREEMENT

I certify that the above statements are true and correct, and that I,
_________________________, having been advised and informed fully by
___________________________________ of ______________________________
concerning the nature of the treatment process proposed, to be administered by
them, hereby authorise and direct them to administer such procedures as may be
deemed necessary or advisable. My signature below constitutes my
acknowledgement that (1) I have read, understand and fully agree to the
foregoing consent; (2) the proposed treatment process has been satisfactorily
explained to me and I have all the information which I desire and (3) I hereby
give my consent and authorisation and release this establishment and its agents
of any claims that I have in the future in connection with the described
treatment.

Client’s Signature:_________________________________ Date:__________

Therapist’s signature:______________________________ Date: __________