Sensitive Region Consent
I, (Patient's First Name Patient's Last Name) have requested this assessment and/or treatment by Brittany A Humes R.M.T, C.M.A.G for treatment of the Buttocks-Gluteal Muscles, Inner Thigh and or Chest Wall, for the purposes of treating one the following clinical indications:
As part of my therapeutic assessment and massage therapy treatment, I am aware that Brittany A Humes R.M.T, C.M.A.G will touch the Buttock-Gluteal Muscles, Inner Thigh and or Chest Wall, of my body. Brittany A Humes R.M.T, C.M.A.G has explained the following to me and I fully understand the proposed assessment and/or treatment including:
- Reduced range of motion in the areas.
- Impaired muscle performance and function.
- The presence of congestion, swelling or edema associated with soft tissue injury.
- The presence of pain or tenderness of a benign origin.
- The presence of soft tissue integrity issues in the region including trigger points, tendinopathies, and sprain or strain injuries.
- Impaired postural control and function.
- Impaired function of the muscles associated with respiratory function.
- Lymphatic drainage issues including congestion, swelling or edema.
- Breast tissue impairments resulting from concurrent health diagnosis. (i.e. cancer)
- Scar tissue/post-surgical management.
- To reduce or eliminate soft tissue impairments in the upper inner thigh and anterior pelvic/groin areas that have been identified as significant and relevant to the achievement of treatment plan goals.
As part of my therapeutic assessment and massage therapy treatment, I am aware that Brittany A Humes R.M.T, C.M.A.G will touch the Buttock-Gluteal Muscles, Inner Thigh and or Chest Wall, of my body. Brittany A Humes R.M.T, C.M.A.G has explained the following to me and I fully understand the proposed assessment and/or treatment including:
- The nature of the assessment and/ or treatment, including the clinical reason(s) for the assessment and/or treatment of the above area(s) and the draping methods to be used.
- The expected benefits of the assessment and/or treatment.
- The potential risks of the assessment and/or treatment.
- The potential side effects of the assessment and/or treatment.
- Alternative course(s) of action.
- Likely consequence of not having the assessment and/or treatment.
- That consent is voluntary.
- That I can withdraw or alter my consent at any time. I voluntarily give my consent for the assessment and/or treatment as discussed and outlined above.
- The client has the right, at any time, to remove any of the consent applied above with a verbal indication.
