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Active Remedial Massage WA

Client Digital Health Form

 

Today's date: November 15, 2018

CONSENT FOR TREATMENT: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialists for any mental; or physical ailment that I am aware of. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.This facility reserves the right to refuse services at their discretion based upon the patient conditions, practitioners skill set, patient attitude or action, without explanation or prior notice, and I agree to this policy.

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
HEALTH HISTORY

Please list areas of main concern and describe your symptoms below.
Grade your symptoms (if any) on a scale of 1 - 10*

When and how did your symptoms begin?

Have you had any previous surgery/injury that will influence today's treatment?

List the medications and/or vitamins you are taking (prescription and non-prescription):
Have you received remedial massage before?*
No
Yes
Preferred type of massage/pressure:*

Do you have or have had any of the conditions stated below:

Headaches/Migraines
Back/Neck Problems
Fibromyalgia
Chronic Fatigue
Asthma
Kidney Disease
Liver Disease
Decreased Sensation
Severe Pain
Nausea/Vomiting
Cancer/Tumour
Chemo/Radiation
Lymphatic Condition
Inflammation
Stroke/CVA
Blood Clot
Heart Attack/MI
Blood Pressure Low
Blood Pressure High
Varicose Veins
Stomach Ulcers
Hip Joint Stiffness
Dislocated Joints
Arthritis
Osteoporosis
AIDS/HIV
Seizures
Neuropathy/Numbness

Current condition:If yes to any of the above, please explain current condition:

Past condition:If yes to any of the above for a past condition, please explain the past condition:

Please list additional comments regarding your health and wellbeing that you think your practitioner should know:

Do you have any of the following today?

 (Please note you may be turned away from your initial treatment or may not receive the full treatment if you have ticked some of the conditions stated below)

Cold & Flu/Fever
Pitted Oedema
Open Cut
Thrombosis/Deep Vein
Infection/Skin Rash
Contagious Disease
Bruise
Spinal Disc Herniation/Slipped Disc
Pregnant/Planning Pregnancy
Kidney Disease
Diarrhoea
Severe Pain
Vomiting
Sharp Pain
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation:
Do you have Private Health Cover*
No
Yes

If so, please State Health Fund. Note: A physical address will be required to be filled out on this health form (below) if you wish to claim rebates back.
Do you have a Concession Card?*
No
Yes

List Allergies:
How did you hear about us?*
Please check if you do not wish to receive sms and email reminders.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent you may request from your practitioner to receive a signed copy of this health form waiver to keep for your own records. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. Your signature will not be used for any other purpose but for health intake purpose for your treatment at Active Remedial Massage WA. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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