Kinesiology Informed Consent Form
Please complete this form before your kinesiology session so the practitioner can record your details, session information, relevant readiness notes, and consent acknowledgment.
Participant Details
Participant Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Session Information
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Practitioner / Therapist Name
*
Health and Readiness Information
Current concerns or goals
*
Known injuries or physical limitations
Allergies or sensitivities
Submit
Should be Empty: