EmailMe Form - Massage Consent Form

Personal Details

Name: *

Address: *

Suburb: *

Postcode: *

Email Address: *

Gender: *

Date of Birth: *

Occupation:

Private Health Insurance Provider:

Next of Kin Details

Please provide details of the person you would like us to contact in case of an emergency

Name: *

Relationship:

Contact Number: *

Please list current types & frequency of exercise.

What is the main reason for this appointment?

How would you like to be reminded of your next appointment? *

Do you consent to receiving promotions from South Yarra Fitness? *

Yes

No

Medical History

Please provide relevant medical history

Details of recent illnesses or surgeries - please provide dates.

Allergies:

Current Medications:

Do you have a current or recent history with any of the following conditions?

Pneumonia

Yes

No

Diabetes

Yes

No

Hepatitis

Yes

No

Cancer

Yes

No

Heart Disease

Yes

No

Glandular Fever

Yes

No

Current Pregnancy

Yes

No

Review & Submit

I understand cancellations require no less than 24hrs notice by telephoning South Yarra Fitness on 03 9827 0083 or Andrew on 0422 883 520.
Late cancellations will incur a 50% cancellation fee.

I have accurately declared all injuries and medical conditions and consent to treatment.

How did you find out about us?
If through Google, please list the search term that led you to us.
If through Facebook, please specify which page (South Yarra Fitness, Andrew O'Connor - Musculoskeletal Therapist, etc).
If you were referred to us, please include the persons name who referred you to us. *