Client information

Yuka's Remedial Massage Client Information Form

Complete form below to book your massage appointmet at the first time.
Full Name

PrefixFirst NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Phone Number

Area CodePhone Number
Birth Date

DayMonthYear
Private Health Fund
Emergency Contact

First NameLast Name
Emergency Contact Number

Area CodePhone Number
Do you have any of following conditions ?
Have you had any major injury or surgery that still affect your health, mobility or flexibility?
Please explain your injury or surgery. When did you have it? How did it happen?
Are you on medication?
If you are on medication, what are you taking and how often?
Please explain any other conditions that the therapist needs to be aware of
Major complain
Pain/discomfort level
What seems to be a cause of your pain/discomfort?
How long do you have the major complain?
Where did you hear about us?

Other
I acknowledge that massage therapy is not a medical diagnosis and treatment. I understand that my massage treatment program is an ongoing process that requires regular attendance to be effective.

I understand that the therapist has the right to discontinue providing services at any time for any reason deemed appropriate.
Do you agree to the above conditions ?
Paypal payment, Entre your consultation fee in the below to make a Paypal payment if you have not paid yet. Contact 0413 747 809 for availabilitiy and prices in your area.

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Yuka's Remedial Massage Client Information Form

Paypal payment, Entre your consultation fee in the below to make a Paypal payment if you have not paid yet. Contact 0413 747 809 for availabilitiy and prices in your area.