MEDICAL CONSULTATION FORM
Do you have or have you had any of the conditions listed below in the past year’s?
Y/N
Y/N
Y/N
Pacemaker or pacemaker leads HIV positive YN Recent illness YN
Heart condition YN Recent operation YN Metal implants, screws or prosthesis YN
Cancer/consensus lesions YN Diabetes YN Allergies to rubber, copper or Other metals YN
Inflammation, Infection or tumour in any area YN Allergies YN Lack of normal skin sensation YN
Muscular condition YN Varicose veins YN High/low blood pressure YN
Contact dermatitis or other skin disease YN Epilepsy YN Any condition under medical care YN
Are you taking muscle relaxants YN Are you taking any anti-depressants YN Are you pregnant YN
Recent scar tissue YN Phlebitis or thrombosis YN Multiple sclerosis YN
Hepatitis YN        
I Certify that the statements I have made are true and correct, and that I, having been advised and fully informed concerning the nature of treatment process proposed to be administered, hereby authorise and direct you to administer such processes and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowledgement that (1) I have read, understood and fully agree to the foregoing consent. (2) The proposed treatment has been satisfactorily voluntarily and release you and your agents of any claims that I have or may have in the future in connection with the described treatment.