New Client Form

New Client Form

Please complete the questions on this form to the best of your ability. I will review your responses in preparation for your first consultation and treatment with Orange Massage and Yoga. Marie Thomas - remedial massage therapist and yoga instructor
My Contact & Personal Details
I am*

FemaleMale
Legal Name*

First NameLast Name
I prefer to be called*
My date of birth is*

DayMonthYear
My occupation is
Provide your primary occupation
I reside at*
Street name and number
in*
City or town where you live
State*
Postcode*
My email address is*
I heard about Orange Massage and Yoga by*

Word of mouth / reputationFacebook pageFacebook adGoogle searchGoogle adWebsiteOffice locationOther
My Health History
Please select any conditions you currently experience or have experienced

Blood pressure irregularityHeart condition of any typeVaricose veinsThrombosis / blood clotsEpilepsyHeadaches / migrainesCancer / malignancyAsthmaDiabetesEasy bruisingSkin sensitivity / skin rashesAbscess / open soresAllergiesArthritisHerniated discsAny contagious diseases eg. hepatitis C
Please give details about any of the conditions you've listed above
Where possible, includes dates and treatments provided

Indicate your current mental / emotional stress level*

	1	2	3	4	5	6	7	8	9	10

1 is Not stressed, 10 is Extremely stressed

Are you pregnant?

NoYesUnsure
Have you ever suffered any fractures or dislocations or experienced any surgeries or illness requiring hospitalisation?*

NoYes
Please provide details for the fractures, dislocations, surgeries, hospitalisations etc you've experienced
Do you participate in regular physical activity?*

NoYes
Please describe these physical activities
Include weekly frequency of participation
Are you currently taking any medications or drugs of any kind*

NoYes
Please list these medications and the reasons for their use
Are you aware of any tension or muscle soreness in your body?*

NoYes
Where in your body do you feel this tension / soreness?
Informed Consent
By typing my initials in the box below, I give my consent to Orange Massage and Yoga to provide massage therapy treatments to me. I understand that all massage treatments, my personal information and records will be kept confidential and securely stored for use only by practitioners directly associated with my treatment. Written consent must be provided by me to release this information to any third party not directly related to my treatment. My privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment. Draping will be used by the therapist as required to expose only those parts of my body that require treatment.
I hereby give my informed consent to Orange Massage & Yoga for the purpose of providing massage therapy services *
Please type your initials here
Cancellation and Late Arrival Policy
By typing my initials in the text box below, I understand that;

- in the event of being late for my appointment, my massage duration may be reduced and in such cases the massage fee will be maintained as per the Orange Massage and Yoga fee schedule

- if I do not attend my appointment or if I provide less than 24 hours notice to cancel my scheduled appointment, I remain responsible for the full payment of all fees associated with the appointment
I agree to and accept the cancellation and late arrival policy*
Please type your initials here
Today's Date

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Date
Should be Empty:

New Client Form

My Contact & Personal Details

My Health History

Informed Consent

Cancellation and Late Arrival Policy