Lavande Difference
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Lavande Difference
Services
Therapist
Policies
Forms
Contact Us
Kinesio-tape Consent
Kinesio-tape Consent Form
Name
*
First Name
Last Name
Email Address
*
Phone Number
*
Have you used Kinesio tape before?
*
No
Yes
List any sport activites, hobbies, or exercises done on a regular basis
Briefly explain any past or present injuries
Kinesiotape is a form of athletic cotton tape which is bonded with 100% medical grade acrylic adhesive. By initialing below, I understand that redness may result and may last a couple days after removal of the tape.
*
Kinesiotape is not recommended for sensitive/thin skin. By initialing below, I understand it is my responsibility to inform my therapist prior to service if any concerns exist.
*
Have you had a lymph node removed in the past?
*
Precautions are necessary when using kinesio-tape to ensure lymph is not directed toward the area of the absent lymph node, which could lead to worsening of lymphedema
No
Yes
Do you have any of the following medical conditions: Deep Vein Thrombosis (DVT), Renal Insufficiency, Congestive Heart Failure, Diabetes, Infection, or Cancer?
*
Kinesio-tape may not be placed anywhere while any of the above medical conditions are present.
No
Yes
By initialing below I consent to kinesio-tape application. I understand it is my responsibility to inform my massage therapist of any concerns or changes to my medical information prior to any sports tape application.
*
By initialing below, I acknowledge that sensitivity to the tape could occur and it is my responsibility to remove the tape if a reaction occurs
*
Kinesio tape may be worn for up to 3 days. After which it is the client's task to gently remove the tape application.
Thank you!
Health History
Utah Massage Waiver
Lava Shell Consent
Soft Cupping Consent
Prenatal Massage Form
Kinesio-tape Consent
