Client Information and Consent Form - PHILLIP ISLAND MASSAGE THERAPY

Name *

First

Last

Mailing Address *

Telephone *

Email *

Occupation

Health Fund

If you do not have a health fund, then leave blank.

Emergency contact name and phone number *

Doctor Name and Phone Number

(If pregnant) number of weeks pregnant

Do you have any children? If so how many?

Please indicate if you have any of the following conditions:

What is your smoking status?

Do you have any scars? If so, where?

Do you have any injuries or are you experiencing any pain or discomfort?

What medication are you currently taking? (if any)

Leave blank if none

What is the reason for today's visit and how often do you have massages? What type(s)?

How did you hear about us?

Would you like to hear about future PIMT massage promotions and specials?

Do you agree to our our Privacy Policy? (Required for treatment) *

Yes

Phillip Island Massage Therapy Privacy Policy . By submitting this form you gurantee that the information provided is current and true. I will inform the therapist of any future changes and acknowledge that there will be no liability of the therapist's part should I fail to do so, or if I have failed to disclose any other relevant information. I hereby give consent for Phillip Island Massage Therapy to proceed with my treatment.