Client Registration

Client Registration Form
Personal Information
Given Name(s)
Surname
Mobile No.
Date of Birth

DayMonthYear
Primary Contact No.
Email
For Appointment Confirmation and correspondence.
Address Information
Street No.
Street Name
Suburb
Post Code
State
Lifestyle

The following questions are optional but do greatly reduce assessment time
No. of Children
Ages of children
Occupation
Average Hrs at Work
Per week
Type of Work
Emergency Contact Information
Given Name
Surname
Contact Number
Health Fund Information

If you are a Private Health Fund Member, please provide the following details...
Health Fund
i.e Medibank, Bupa, HCF, NIB
Membership Number
Please note: not all Therapies offered are covered by Private Health Insurance. Administration will contact you promptly if your selected Therapy falls outside Private Health Cover.
Refferal

If you have been refered by a Doctor/ Allied Health practioner, please provide their details below
Name of Practioner
Practice Name and Suburb
Contact No.
Type of Practioner
Treatment Options

Please select the Treatment(s) you are interested in
Massage Therapy
Polarity Therapy
Reiki
Mobile/ Corperate Massage
Acknowledgement
I accknowledge that this information is collected to form part of my initial Registration and Health Assessment. I also acknowledge that i will be required to sign a copy of this form at the commencment of my first treatment.
Registration Fee: $25

To secure your Appointment a fee of $25 is required. This amount will be deducted from the total cost of you first attended Appointment. This will be processed via PayPal if you choose to proceed. If you are unsure please direct your query via the Contact us page on the main site.
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Client Registration Form

Personal Information

Address Information

Lifestyle

Emergency Contact Information

Health Fund Information

Refferal

Treatment Options

Acknowledgement

Registration Fee: $25