Please complete and submit the form below or alternatively download, complete and return the PDF form.
[vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]
[/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column width="1/2"][vc_column_text]Name (required) [/vc_column_text][/vc_column][vc_column width="1/2"][vc_column_text]Initial Visit Date [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Address [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column width="1/2"][vc_column_text]Post Code [/vc_column_text][vc_column_text]Phone [/vc_column_text][/vc_column][vc_column width="1/2"][vc_column_text]Date of Birth [/vc_column_text][vc_column_text]Mobile [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Email (required) [/vc_column_text][vc_column_text]Occupation [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column width="1/2"][vc_column_text]Emergency Contact [/vc_column_text][vc_column_text]Referred by [/vc_column_text][vc_column_text]Doctor [/vc_column_text][/vc_column][vc_column width="1/2"][vc_column_text]Phone [/vc_column_text][vc_column_text]Health Fund [/vc_column_text][vc_column_text]Extras Cover YesNo[/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]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.[/vc_column_text][vc_column_text]Physical/recreational activities: [/vc_column_text][vc_column_text]Sleeping Patterns: [/vc_column_text][vc_column_text]Have you had a massage before? [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column width="1/3"][vc_column_text]Preferred pressure during massage LightMediumFirm[/vc_column_text][/vc_column][vc_column width="1/3"][vc_column_text]Do you experience any difficulty lying on your front/back? YesNo[/vc_column_text][/vc_column][vc_column width="1/3"][vc_column_text]Have you had any recent surgery? YesNo[/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]General health/wellbeing: [/vc_column_text][vc_column_text]Main reason for visit today – eg. Relaxation, pain relief, stress [/vc_column_text][vc_column_text]History of presenting problem (how it happened, current symptoms, duration etc.) [/vc_column_text][vc_column_text]Behaviour of pain – constant/with movement/with activity/sharp/shooting/dull aching [/vc_column_text][vc_column_text]Aggravating factors – activities/postures/stresses [/vc_column_text][vc_column_text]Relieving factors – movement/rest/posture/heat/cold [/vc_column_text][vc_column_text]Previous treatment for complaint [/vc_column_text][vc_column_text]Treatment Goals – what would you like to get out of your treatment? [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]
[/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Are you currently under medical/therapeutic treatment? YesNo[/vc_column_text][vc_column_text]If so, for what condition? [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern" background_color="#eaeaea"][vc_column][vc_column_text]
[/vc_column_text][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Bone or joint; sprains/strains; fractures; soft tissue; whiplash YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Osteoporosis YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Arthritis YesNo[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Details / Notes: [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern" background_color="#eaeaea"][vc_column][vc_column_text]
[/vc_column_text][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Headaches YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Migranes YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Numbness/tingling/weakness YesNo[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Details / Notes: [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern" background_color="#eaeaea"][vc_column][vc_column_text]
[/vc_column_text][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Heart Condition YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]High / Low blood pressure YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Varicose veins; blood clots YesNo[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Details / Notes: [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern" background_color="#eaeaea"][vc_column][vc_column_text]
[/vc_column_text][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Asthma YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Sinus problems; hay fever YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Breathing difficulties YesNo[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Details / Notes: [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern" background_color="#eaeaea"][vc_column][vc_column_text]
[/vc_column_text][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Medication YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Skin condition / disorder YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Other YesNo[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Details / Notes: [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern" background_color="#eaeaea"][vc_column][vc_column_text]
[/vc_column_text][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Pain YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Anti-inflammatories YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Respiratory YesNo[/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Blood Thinners YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Other YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text][/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Details / Notes: [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern" background_color="#eaeaea"][vc_column][vc_column_text]
[/vc_column_text][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Cancer YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Diabetes YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Pregnant YesNo[/vc_column_text][/vc_column_inner][/vc_row_inner][vc_row_inner row_type="row" type="full_width" text_align="left" css_animation=""][vc_column_inner width="1/3"][vc_column_text]Epilepsy YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text]Other YesNo[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_column_text][/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]Details / Notes: [/vc_column_text][vc_column_text]Other comments: [/vc_column_text][/vc_column][/vc_row][vc_row css_animation="" row_type="row" use_row_as_full_screen_section="no" type="full_width" angled_section="no" text_align="left" background_image_as_pattern="without_pattern"][vc_column][vc_column_text]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.[/vc_column_text][vc_column_text]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.[/vc_column_text][vc_column_text]
I, 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: Full body including all the below areas OR backButtocksLegsFeetArmsStomachChestFaceHead
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) - typed name denotes signature through online method Date (required)
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