Patient´s consent
This declaration must be returned before the start of the treatment.
I declare that I stall observe all the above instuctions and that I do not suffer from any of the conditions or illnesses stated below – contra-indications for Whirlpool bath, Alternating leg shower, Aromatherapy overall, Classical massage overall, Hot Stone massage, Honey massage, Reflex foot massage, Underwater massage, Cupple massage, Parafin wrap, Peat wraps small (2 places), Lymph drainage of lower limbs by appliance, Cinnamon Pack anti- cellulite.
- Acute ifection or other serious or feverous illness
- Serious cardiovascular disease, allodromy, unstable high blood pressure higher than 160/100, unstable angina pectoris, acute or post myocardial infarction or heart malfunction – I do not have a cardiac pacemaker
- Inflammation and other skin or subcutis disease, damaged skin at the place of application, including fungus disease
- Onkological disease, aktive tuberculosis
- Acute phlebitis (or 6 months after inflammation) or deep/arterial thrombosis conditions
- Extensive varicose všine of the lower limbs or venous ulceration ( I do not have a post-venous ulcer condition) – where treatment is applied to lower limbs
- Blood coagulability interferences – I do not use so cold anti-coagulation or blood dilution medication (e.g. Warfarin)
- Serious interferences of lower limbs blood circulation
- Serious neurological disease especially connected with skin sensitivitz interference
- I have no allergy to cinnamon (in the event of a cinnamon wrap)
- I am not allergic to honey (in the event of honey massage)
- I am not pregnant (ladies only)
I also declare if anz changes in mz health have occurred, I have an obligation to disclose this fact.
First name and surname .................................................................................
Date of birth ................................................................................................
Permanently resident at .................................................................................
Karlovy Vary, on .............................. Client´s signature ....................................
