Client History Form - Boort Natural Therapies
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Client History Form

Please complete and submit the form below or alternatively download, complete and return the PDF form.

Client Details

Name (required)

Initial Visit Date


YesNo

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.


LightMediumFirm


YesNo


YesNo

Medical History


YesNo

Musculoskeletal:


YesNo


YesNo


YesNo

Nervous:


YesNo


YesNo


YesNo

Cardiovascular:


YesNo


YesNo


YesNo

Respiratory:


YesNo


YesNo


YesNo

Allergies:


YesNo


YesNo


YesNo

Current Medication:


YesNo


YesNo


YesNo


YesNo


YesNo

Other:


YesNo


YesNo


YesNo


YesNo


YesNo

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, 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.