Your Name: *


Your Email: *


Address: *


Mobile Phone: *


Treatment type: *
Remedial Massage
Post surgery (lymphatic drainage and scar tissue treatments)

Your age:


Gender:
Female
Male

Occupation:


Private Health Fund:


Emergency contact name and phone:


What is being treated at this appointment:


Modalities that interest you:
Soft tissue injury treatment
Sports massage / deep tissue massage
Relaxation massage / stress relief / hot stones
Hawaiian massage
Manual lymphatic drainage

Massage pressure preferred:
Light
Moderate
Deep
Very Deep

Sports or hobbies that you participate in that may effect your muscles:


Medical conditions relevant to this treatment:


Medications:


Any questions or concerns relating to the upcoming treatment:


How did you find out about Fitnwell Massage:
Referred by another therapist
Online search
Drive past
Referred by a friend