Shockwave Therapy Enquiry Form

Full Name

Phone Number

Address

Age

Have you attended Life Fit Wellness before?

Yes No

If you know or think you know your diagnosis please provide details:

Have you had any previous treatment for this issue?

Rehabilitation (led by physiotherapist, chiropractor, osteopath, sports therapist) Therapeutic Ultrasound Treatment Laser Therapy Other electrotherapy (i.e. interferential, TENS) Acupuncture or Dry Needling Injection therapy (i.e. steroid/cortisone, hyaluronic acid, PRP) Manual therapy (i.e. massage, manipulation, mobilisation) Other

If you selected 'Other', please provide details

Shockwave therapy may not be appropriate if; You are pregnant • You are being treated for cancer • You have an infection or wound at the treatment site • You have had a steroid injection in the previous 6 weeks • You have metal pins, plates or prothesis in the area requiring treatment • You have a blood clotting disorder • You are under 18• You are taking anticoagulant medication • If there is a reason you may not be able to have shockwave treatment then please outline why below.

Please use this space to ask any questions you may have or provide any further information you think may be helpful.

I hereby agree to Life Fit Wellness contacting me in relation to the above enquiry

I agree

Shockwave Therapy Enquiry Form

Please complete this form if you are interested in Shockwave Therapy for soft tissue and joint problems. Once we have reviewed your answers we will be in touch.

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Opening Hours

Mon	8:00am - 7:30pm
Tue	8:00am - 4:30pm
Wed	8:00am - 7:30pm
Thu	8:00am - 7:30pm
Fri	8:00am - 4:00pm
Sat	9:00am - 1:00pm
Sun	Closed