North Brisbane and Ferny Chiropractic Clinic

Massage Client Case History and Consent Form

Massage Form
Title
Address
Address
Suburb
State
Postcode
Do you currently suffer from any of the following conditions:
Have you suffered in the past from any of the following conditions:
Are there any other conditions that I should be aware of?
Are you pregnant or likely to be pregnant?
Remedial Massage may include face, head, chest, stomach, back, buttocks, arms, legs and feet depending on the area of the problem.
  • Remedial Massage therapy is provided for stress reduction, relief from muscular tension, improvement in postural function and improvement of circulation and energy flow.
  • Remedial Massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat physical or mental illness. If you are in doubt, consult your medical practitioner.
  • If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/ strokes can be adjusted to my level of comfort. I understand that Remedial Therapy involves deep soft-tissue work, and depending on the severity of the problem it is normal to feel some muscle soreness and tenderness within the days following the treatment.
  • I affirm that I have notified my therapist of all known medical history and I agree to inform the therapist of any changes in my health and any medical condition.
  • I give consent, by signing below, to cover the entire course of treatment for my presenting complaint(s), and for any other future condition(s) for which I seek treatment from the below named Remedial Masseuse and any of the registered Practitioners practicing at North Brisbane Chiropractic.
  • I have read, or have had read to me the above consent and I have also had an opportunity to ask questions about this content.