*Please fill out the below information Please enable JavaScript in your browser to complete this form. Please enable JavaScript in your browser to complete this form. Name * Date of Birth * DD/MM/YY Address * Mobile No. * Work No. Email * Occupation How were you referred to us? Name of referrer Do you participate in regular exercise? Please describe. What are your main areas of concern? prescribed Are No. Pain Rating from 0-10(0=no pain, 10=extreme pain) Are you currently undergoing any other treatment? Please describe. Practitioner Name Practitioner Contact No. Are you pregnant? Yes No Do you have a history of any surgeries? Please describe. Are you currently taking any prescribed medications? Please list. What type of massage style are you after today? * Bowen Therapy – $100.00 Lymphatic Drainage Massage – $110.00 Note: Bowen Therapy treatments are done through light clothing, so please don’t wear denim or non-stretch tight clothing. Declaration * I declare I have given to the best of my knowledge, all relevant information that is known to me to be true and correct. I have disclosed all conditions to my therapist that may contraindicate this treatment. I am also aware that there will be no medical diagnosis given, and that this is only a complimentary therapy to any current conditions. Submit
