Consent for Assessment and Treatment of Sensitive Areas

E-mail address:

have requested assessment and/or treatment by the practitioner identified below.

Practitioner:

For assessment and/or treatment of the clinically relevant area(s) indicated below:

Gluteal muscles Upper inner thigh Chest / Chest wall Breast tissue Other sensitive area

If other, specify:

The practitioner has explained the following to me, and I confirm that I understand:

The nature and purpose of the assessment and/or treatment, including the reason for working on the sensitive area(s) identified above.
The draping procedures that will be used to protect my privacy, comfort, and dignity.
The expected benefits of the proposed assessment and/or treatment.
The reasonably foreseeable risks, discomforts, and possible side effects.
That I may ask questions before or during the session.
That my consent is voluntary.
That I may refuse or withdraw my consent, in whole or in part, at any time before or during the assessment or treatment without affecting my ability to receive other appropriate services.

I voluntarily give my informed consent for the assessment and treatment described above.
At the conclusion of today’s appointment, I confirm that I have had the opportunity to discuss any questions or concerns with the practitioner. To the best of my knowledge, I have no immediate concerns regarding the assessment or treatment provided today.
I understand that temporary soreness, tenderness, bruising, fatigue, or other mild post-treatment reactions may occur. If I experience unexpected symptoms or concerns after leaving the appointment, I understand that I should contact the practitioner promptly and seek appropriate medical care when necessary.

Client name:

Client signature:

Date:

I confirm that I have read and understood this consent form and had the opportunity to ask questions before signing.