Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency's Phone

(###)

###

####

Are you currently taking any medication? *

Yes

No

Do yo suffer from chronic pain? *

Yes

No

Have you had any orthopedic injuries? *

Yes

No

Please indicate any condition you have had in the past or currently suffer from *

Cancer

Headaches / Migraine

Arthritis

Diabetes

Joint replacement(s)

High / low blood pressure

Neuropathy

Fibromyalgia

Stroke

Heart attack

Kidney disfunction

Blood clots

Numbness

Sprains or strains

none

Are you currently pregnant?

Yes

No

Have you had any therapeutic treatment before? *

Yes

No

Are you sensitive to fragrances? *

Yes

No

Please read carefully *

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

I accept

24-hour Cancellation Policy *

I am aware that a 24-hour notice to cancel or re-book a service applies. If a reschedule of my appointment is placed less than 24 hours prior to the appointment or I do not attend my appointment on the day, I will be charged the full amount for the scheduled session.

I accept

Deposit for the first booking *

This is a non-refundable deposit, required for the booking of your first appointment.

I accept CC payment over the phone

New practice health and safety regulations apply during COVID19 *

Any person (whether an Australian citizen or not) that enters Australia or has been in a hotspot area such as Victoria has to go on to a 14-day, self-isolation period and is not accepted for any visit at our clinic during that time. Any person feeling unwell or sick and is having symptoms that could be related to COVID19, such as fever, cough, runny nose and shortness of breath, has to let the practitioner know. This will immediately result in termination of the appointment.    The clinic will continue to operate under the following rules: The equipment in the treatment room, e.g. the treatment bench, the door handles and surfaces etc. will be cleaned and sanitised after each patient. The bathrooms have single use paper hand towels and soap. The entrance of the clinic for you, my clients, will be on the right side of the building (a sliding door). This ensures that you do not have to walk through the doctors surgery which won’t expose you to other patients in the clinic. The waiting area is in front of the treatment room for you from now on. Washing hands after arrival at the clinic is required as well as additional hand sanitising and also temperature taking has been put in place too. For the time of the treatment, I can offer you a face mask if required.

I accept

Date *

MM

DD

YYYY