Massage Client Case History and Consent Form

First name

Last name

Preferred name

Date of birth (dd/mm/yyyy)

Address

Suburb

State

Postcode

Home

Work

Mobile

Occupation

Private health insurer

Who can we thank for referring you to us?

Are you happy to receive SMS reminders for upcoming appointments?

Yes

We send out a monthly newsletter, do you wish to receive this?

Yes

How long since your last massage?

Are there any other conditions that I should be aware of?

Yes

If yes, please provide details:

Please provide details of any other treatment you’ve had (eg: acupuncture/chiro/physio)

Are there any medications you are currently taking?

Are you pregnant or likely to be pregnant?

Yes (how many weeks?)Yes (how many weeks?)

Reason for visit/presenting complaint

Please put an (X) on any areas of concern for treatment today

Remedial Massage may include face, head, chest, stomach, back, buttocks, arms, legs and feet depending on the area of the problem.

Please indicate any area you would not like to have included in the massage

Remedial Massage therapy is provided for stress reduction, relief from muscular tension, improvement in postural function and improvement of circulation and energy flow.
Remedial Massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat physical or mental illness. If you are in doubt, consult your medical practitioner.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/ strokes can be adjusted to my level of comfort. I understand that Remedial Therapy involves deep soft-tissue work, and depending on the severity of the problem it is normal to feel some muscle soreness and tenderness within the days following the treatment.
I affirm that I have notified my therapist of all known medical history and I agree to inform the therapist of any changes in my health and any medical condition.
I give consent, by signing below, to cover the entire course of treatment for my presenting complaint(s), and for any other future condition(s) for which I seek treatment from the below named Remedial Masseuse and any of the registered Practitioners practicing at Noosa Chiropractic and Skin Health Noosa.
I have read, or have had read to me the above consent and I have also had an opportunity to ask questions about this content.

Client's signature

Client's name

Date (dd/mm/yyyy)

Chiropractor's signature

Chiropractor's name

Date (dd/mm/yyyy)

Please like the Noosa Chiropractic Facebook page to keep in touch.

If you are human, leave this field blank.