New massage patient registration form - City

New massage patient registration form - City

   

                Massage Therapy Registration Form -City

 

Title:_____First Name: ____________________________Surname: _______________________

 Address: _______________________________________________________________________  

 Suburb: _______________________________________       Post code: _____________________

 Date of Birth: _____/_____/_____     

 Contact Numbers:     

 Home: _____________________                        Work: _____________________

 Mobile: ____________________                       Fax:  _____________________

 Email Address: ___________________________________________________________

 Occupation: ______________________________________________________________

 Private Health Fund: ______________________________________

 Medication/ Allergies (Specifically Nuts): _______________________________________

 Is this a Workers Compensation Claim?   Yes   /   No

 

Sports / Exercise                                  Time per week (e.g. 1 hour)

______________________                ______________________

______________________                ______________________

 Referral Source:           Word of Mouth: Name: ______________________________

GP/Specialist: ______________________________________

                                   Website: __________________________________________

Other: ____________________________________________

 

Please circle if you have or had any of the following symptoms/ conditions in the last 12 months:

Osteoporosis      Chronic Pain      Kidney Ailments      Loss of Balance      Sleep Disorders

Cold/Flu/Fever    Herpes             Psoriasis                 Insomnia               Infectious Conditions

Numbness          Blood Clots       Neck/Spine injury    Heart Ailments       Joint replacement

Eczema              Dizziness          Epilepsy                  Fatigue                  Nervousness

T.M.J.Syndrome  A.I.D.S             High blood pressure P.M.S. Syndrome    Allergies

Arthritis              Headaches        Phlebitis                 Cancer                   Depression

Diabetes             Shingles           Digestion Problems  Varicose Veins        Skin Disorders

 

 What’s the main reason for your massage visit today? ____________________________________________

 _________________________________________________________________________________________

 Cancellation Policy in accordance with the Australian Physiotherapy Association

Our practice requires 24 hours notice if you wish to cancel your appointment. This provides the practice with the opportunity to offer the appointment to other patients. If 24 hours notice is not provided and you do not attend, you may be charged a cancellation fee. Motor Accident Insurance and Workers Compensation does not cover charges for non attendance. These charges will need to be met by the patient.

 

Patient Signature: __________________________ Date: _____/_____/_____

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Pitt St. City Practice

Address:
Level 7 60 Pitt Street Sydney 2000
Hours of Operation:
Mon - Fri 7:30am - 6:00pm
Telephone:
(02) 9251-5111

King Street Practice

Address:
Fitness First - The Zone / 94 King Street Sydney 2000
Hours of Operation:
Mon - Fri 7:30am - 6:00pm
Telephone:
(02) 9251-5111