Fit'n'Well Massage

Thank you for making a booking with Fit n Well !!!


If this is your FIRST appointment with Fit n Well please complete this form below.

Doing this before your appointment will leave more time for the treatment itself.

If you have had a previous appointment with Fit n Well, you do NOT need to complete this page again.


Looking forward to seeing you at your appointment time…
Fitnwell Massage: 375 Cobbitty Road, Cobbitty NSW 2570

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Keep Fit and Well…Gary

Fields marked * must be completed please

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Please do not alter this field above

If you are under 18 years of age you must have a parent or guardian present during the massage

Please provide name, relationship and telephone number

Please give the name of the fund if applicable


Type of treatment:

Your massage appointment:
(For Lymphatic Drainage appointments please skip to the next section)

For example "I have lower back pain that radiates down my left leg" or "I just want a massage to help me relax"

Have you suffered an injury that prompted the booking?

0=no pain 10=extreme pain


For Lymphatic Drainage and Post Liposuction Appointments:
(For remedial massage appointments please skip this section)

You can choose multiple options

You can choose multiple options

Name of clinic or doctor’s name

Minimum 6 appointments over 3 weeks

See link below. This page provides essential booking information.

Here is a link to the Lipo Information Page
Opens in a new window so you won't lose your work on this document.

Occupation

Please list


Conditions

Please give the name of the medication and the condition that it is treating

If YES how many weeks?


General

If referred by a friend please mention your friend's name


COVID 19 Status
Consent to provide treatment
Female thoracic spine 1 webAMT_logo_BLACK
Please Note:
You are booking in for a treatment where removal of some clothing will be required to effectively access the area of your body being treated. I am a professional massage therapist & I adhere to strict body draping procedures. I am a member of the Association of Massage Therapists (Member Number 1-10757), and abide by their Code of Ethics.

Persons under 18 years of age are requested to wear sporting attire to the massage appointment.

Cancellation Policy:
Please provide a minimum of 48 hours notice if you intend to cancel or re-schedule your appointment.
Failure to provide this notice will incur the full cost of the treatment.
I hereby give my consent for Gary Bolton to carry out the treatment as detailed above and discussed with my therapist (Gary Bolton) before the consultation.

PLEASE SIGN THE BOX BELOW using your finger or mouse

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