Remedial Massage – initial Consultation

  • GP or Medical Practice detials

  • General Health

  • Lifestyle and Wellness

  • Please select if you currently have or previously had any of these conditions in the past.

  • If you could improve anything about your health, what would be your goals?

  • Please select the area of pain and indicate on a score of 0 to 10, how intense the pain is. (0=no pain, 10=extreme pain)

  • Terms & Conditions

    • I understand that there are possible significant risks and complications specific to my individual circumstances that may have a bearing upon my decision to proceed with the proposed treatment.
    • The therapist has explained the treatment options to me and will discuss with me during the treatment if she/he makes any further changes to the treatment.
    • The therapist has explained the associated risk and possible side effects with this treatment and any potential risks or outcomes if the treatment is changed.
    • The therapist has explained that I have the right to refuse treatment or changes to the treatment and that she/he or I have the right to stop the massage at any time.
    • I understand that I have the right to ask for further information on treatments that include breast, buttock or groin areas and refuse treatment of these areas at any time.
    • I give consent to my patient notes to be shared with practitioners/therapists that work within North Sydney Sports and Chiropractic and will not be used for any other purposes than the treatment of my condition and health..