fascia-consent | INPEAK | Fascia, IBS & Biomechanics

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Your personal details will be kept private and confidential and will only be used for the purposes of your assessment.

ABOUT FASCIAL MANIPULATION

Inpeak provides fascia-focused soft tissue therapy.

This approach works with the connective tissue system (fascia) to support:

• Musculoskeletal pain and restriction

• Digestive symptoms such as IBS and bloating

• Period pain and pelvic discomfort

• Postural and movement dysfunction

This service is not standard physiotherapy treatment and does not replace medical diagnosis or hospital care. Where appropriate, you should continue working with your GP or consultant.

WHAT TO EXPECT

Treatment may involve:

• Targeted soft tissue techniques

• Visceral (organ-related) fascial work

• Pelvic and abdominal techniques

• Self-release guidance

• Exercise or lifestyle recommendations Normal responses may include:

• Temporary soreness

• Mild bruising or skin marks

• Short-term inflammation (1–3 days)

• Temporary symptom fluctuation Most reactions settle naturally within a few days.

I consent to visceral and pelvic soft tissue techniques being used as part of my treatment where appropriate.

I have been advised to obtain medical clearance and am choosing to proceed without it. I understand this is my own decision and that Inpeak may decline treatment if clinically appropriate.'

YOUR RESPONSIBILITY

By signing below, you confirm:

• You have disclosed relevant medical information.

• You understand results vary between individuals.

• You will report any unexpected or severe reactions.

• You are choosing to participate voluntarily.

You may request a chaperone at any time. For clients under 18, a parent/guardian must be present.

Inpeak reserves the right to pause or decline treatment if, in the practitioner's clinical judgement, it is not appropriate based on information provided.

Inpeak accepts no liability for adverse effects arising from conditions or medications not disclosed on this form.

PAYMENT & 24-HOUR CANCELLATION POLICY

• Invoices are payable within 7 days.

• Sessions cancelled with less than 24 hours’ notice are charged in full.

• Missed sessions are non-refundable.

• Packages are non-transferable unless agreed in writing.

I understand that sessions cancelled with less than 24 hours' notice, or not attended, will be invoiced in full and payment will be collected automatically.

Medical History

• Musculoskeletal issues, fractures, disc problems

• Arthritis / osteoporosis / joint replacements

• Heart or blood pressure conditions

• Thrombosis or circulatory issues

• Diabetes / epilepsy / asthma / allergies

• Skin conditions

• Pregnancy / C-section history

• Major surgery

• Digestive / endocrine / neurological conditions

Do you have any of the mentioned?

Yes

If yes, please give brief details of any conditions you have indicated above.

Are you currently taking medication? If yes, please list:

General Wellbeing Sleep:

Energy:

Stress:

Smoking / Alcohol:

Diet:

Please comment on each category

Are you currently pregnant of actively trying to conceive?

Yes

If your health changes significantly between sessions — including new diagnoses, surgery, or pregnancy — please inform Inpeak before your next appointment. A new consent form may be required.

Your personal and medical data is held securely and used only for treatment purposes. It is not shared with third parties. You may request deletion at any time. See our Privacy Policy at inpeak.co.uk/privacy

I confirm I have read and agree to the Fascia Treatment Consent terms and understand what treatment involves.

Type your full name as your signature