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Client Details

Name (required)
[text* client-name]

Initial Visit Date
[date initial-visit]

Address
[text address]

Post Code
[text postcode]

Phone
[tel phone]

Date of Birth
[date birth-date]

Mobile
[tel mobile]

Your Email (required)
[email* client-email]

Occupation
[text occupation]

Emergency Contact
[text emergency-contact]

Referred by
[text referred-by]

Doctor
[text doctor]

Phone
[text emergency-phone]

Health Fund
[text health-fund]

Extras Cover
[checkbox extras-cover exclusive “Yes” “No”]

Whilst massage is generally very beneficial, it may sometimes not be appropriate, or it may need to be modified to best suit your needs and state of health. The following information will assist in establishing this.

Physical/recreational activities:
[text activities]

Sleeping Patterns:
[text sleeping-patterns]

Have you had a massage before?
[text previous-massage]

Preferred pressure during massage
[checkbox preferred-pressure exclusive “Light” “Medium” “Firm”]

Do you experience any difficulty lying on your front/back?
[checkbox lying-difficulty exclusive “Yes” “No”]

Have you had any recent surgery?
[checkbox recent-surgery exclusive “Yes” “No”]

General health/wellbeing:
[text general-health]

Main reason for visit today – eg. Relaxation, pain relief, stress
[text visit-reason]

History of presenting problem (how it happened, current symptoms, duration etc.)
[textarea problem-history]

Behaviour of pain – constant/with movement/with activity/sharp/shooting/dull aching
[textarea pain-behaviour]

Aggravating factors – activities/postures/stresses
[textarea aggravating-factors]

Relieving factors – movement/rest/posture/heat/cold
[textarea relieving-factors]

Previous treatment for complaint
[textarea previous-treatment]

Treatment Goals – what would you like to get out of your treatment?
[textarea treatment-goals]

Medical History

Are you currently under medical/therapeutic treatment?
[checkbox under-treatment exclusive “Yes” “No”]

If so, for what condition?
[textarea treatment-conditions]

Musculoskeletal:

Details / Notes:
[textarea musculoskeletal-notes]

Nervous:

Details / Notes:
[textarea nervous-notes]

Cardiovascular:

Details / Notes:
[textarea cardiovascular-notes]

Respiratory:

Details / Notes:
[textarea respiratory-notes]

Allergies:

Details / Notes:
[textarea allergies-notes]

Current Medication:

Details / Notes:
[textarea medications-notes]

Other:

Details / Notes:
[textarea other-notes]

Other comments:
[textarea other-comments]

CANCELLATION AND NON-ATTENDANCE POLICY
Clients are able to cancel or reschedule an appointment at anytime, without incurring a fee, provided 24 hours notice is given. This allows the opportunity to offer the session to another client. If you cancel with less than 24 hours notice, or fail to attend, you will be charged a Late Cancellation Fee equal to 50% of the full session fee. It is important to note that third parties, (ie Worksafe) will not pay for missed appointments, so you will be responsible for the entire Late Cancellation Fee. Please note also that Late Cancellation Fees are not eligible for Health fund rebates.

UNATTENDED APPOINTMENTS
Late cancellations result in insufficient time to reallocate appointments for those waiting.

In fairness to other clients, we deem it unreasonable to continue offering sessions to those who regularly miss or cancel their appointments at late notice and as such, after 2 unattended appointments you will be required to pay the full session fee at time of booking to secure a new appointment.

Your understanding of this policy and payment on the day is appreciated.

Consent Form

I, [text required consent-name] have chosen to consult with and hereby give consent for massage therapy to be provided by Karen Allison.

Consent is required to massage each part of the body. Please indicate which areas you would like to include:
[checkbox full-body “Full body”] including all the below areas OR
[checkbox individual-parts “back” “Buttocks” “Legs” “Feet” “Arms” “Stomach” “Chest” “Face” “Head”]

It is my choice to receive massage therapy. I realise that the treatment is being given to promote my wellbeing. I agree to communicate with my massage therapist if at any time I feel my wellbeing is being compromised.
I understand that it is not the role of my massage therapist to diagnose injury or illness, or prescribe me medications. I acknowledge that massage is not a substitute for medical examination or diagnosis and that it is recommended I see a primary health care provider for that service.
I understand that massage may provide benefits for certain conditions but results are not guaranteed. These benefits may include relief of muscular tension, relaxation, reduction in the symptoms of stress- related conditions and provision of general wellbeing.

I also understand that massage therapy may produce side effects such as muscle soreness, mild bruising, increased awareness of areas of pain and light-headedness amongst other possible temporary outcomes.
I have stated all medical conditions of which I am aware and will update my massage therapist of any changes in my health status during any further treatments.
I agree to the above cancellation and non-attendance policy.

Signature (required)[text* signature]
Date (required)
[date* submit-date placeholder “YYYY-MM-DD”]

[submit “Send”]