Skip to content
Home
About
Our Clinic
FAQs
Money Back Guarantee
Free Assessment
Patient Registration Form
Massage New Patient Registration
Pre-Exercise Questionnaire
Services
Physiotherapy
Sports Physiotherapy
Clinical Pilates
Massage
Exercise Physiology
Dry Needling
Shockwave Therapy
Common Injuries
Headaches
Neck Pain
Trapped Nerve
Shoulder Impingement
Frozen Shoulder
Tennis Elbow
Low Back Pain
Sciatica
Arthritis
Hip Bursitis
Runner’s Knee
Knee Cartilage Pain
Jumper’s Knee
Shin Splints
Achilles Tendonitis
Ankle Sprain
Plantar Fasciitis
Our Team
Alex van den Berg
Dina Asmi
Leila Van Zuydam
Tom Granger
Daniel Scott
Amy Hondros
Tan Hsin-Wen
Admin Team
Join Our Team
Blog
Contact
Menu
Home
About
Our Clinic
FAQs
Money Back Guarantee
Free Assessment
Patient Registration Form
Massage New Patient Registration
Pre-Exercise Questionnaire
Services
Physiotherapy
Sports Physiotherapy
Clinical Pilates
Massage
Exercise Physiology
Dry Needling
Shockwave Therapy
Common Injuries
Headaches
Neck Pain
Trapped Nerve
Shoulder Impingement
Frozen Shoulder
Tennis Elbow
Low Back Pain
Sciatica
Arthritis
Hip Bursitis
Runner’s Knee
Knee Cartilage Pain
Jumper’s Knee
Shin Splints
Achilles Tendonitis
Ankle Sprain
Plantar Fasciitis
Our Team
Alex van den Berg
Dina Asmi
Leila Van Zuydam
Tom Granger
Daniel Scott
Amy Hondros
Tan Hsin-Wen
Admin Team
Join Our Team
Blog
Contact
Book Online Now
9707 3708
9707 3708
Book Online Now
Patient Registration Form - Massage
Step
1
of
3
– PATIENT INFORMATION
0%
Name
*
First
Middle
Last
Date of Birth
*
MM slash DD slash YYYY
Age
*
Sex
*
Male
Female
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Mobile
*
Do you have private health insurance?
*
Yes
No
If Yes, Fund Name
*
How did you find out about our massage services?
*
Arthur Street Signage
Facebook
Google
From My Physio
Other
Tell Us How?
*
Do you have (or previously had) any medical conditions the therapist is required to know about?
*
Heart Problems
Strokes
Blood Clots
Arthritis
Cancer
Diabetes
Osteoporosis
Surgeries
Whar kind of Surgeries?
*
Are you currently taking any painkillers or blood thinners?
*
Yes
No
If yes, which one(s)?
*
Do you have any allergies to creams or tapes?
*
Yes
No
If yes, which one(s)?
*
Are you currently pregnant?
*
Yes
No
Congratulations! How many weeks?
*
What type of massage would you like?
*
Sports Massage
(This type of massage is beneficial if you have an injury from repetitive muscle use. It may help with improving flexibility and sports performance while reducing your risk of injury.)
Relaxation
(A smooth, gentle flowing style that promotes general relaxation, relieves muscular tension, plus improves circulation and range of movement.)
Deep Tissue
(The perfect option for chronic muscle problems, such as soreness, injury, or imbalance. Deep tissue massage is great if you like added pressure applied during your massages.)
Trigger Point Therapy
(By focusing on relieving the trigger points, it can help reduce pain and is best suited if you have chronic pain, or a specific issue or condition.)
Pregnancy Massage
(A safe massage that can help reduce body aches, stress, and ease muscle tension during pregnancy.)
Reflexology
(Uses gentle to firm pressure on different pressure points of the hands, feet and ears and is a great way to relax and or restore your natural energy.)
Unsure
(It’s fine if you are unsure what type of massage you want. Simply discuss your symptoms with your massage therapist and they will be able to help identify what you are looking for.)
What is your preferred pressure?
*
Light
Medium
Firm
If you would like the massage therapist to adjust their pressure, or concentrate on specific areas during the massage, please let them know at any time. We welcome the feedback as WE ARE HERE TO HELP YOU.
What is your massage talking preference?
*
Happy To Chat
Just Want To Chill & Relax
Not Fussed
Have you seen another massage therapist before?
*
Yes
No
If yes, was there anything you weren’t happy about?
*
I consent to the assessment and treatment recommended and performed by Spine & Sports Physiotherapy in accordance with the governing body’s professional guidelines. This may include soft tissue massage and acupuncture techniques. I understand that before treatment is carried out, a full explanation of the purpose and any risks of that treatment will be provided. I understand that should I wish to decline any form of assessment and treatment, then I am entirely within my right to do so and that I should inform the clinician of my wishes at the time. Spine & Sports Physiotherapy accept no responsibility for treatment received – any professional liability is between the patient and the individual treatment therapist – all therapists are insured via their own personal policies. By signing this form I am in agreement with these terms and conditions.
Patient Signature
Email
This field is for validation purposes and should be left unchanged.