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

0P5A2841 small

Keep Fit and Well…Gary

Fields marked * must be completed please

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Subject *

Please do not alter this field above

Your Name *

Email Address *

Phone *

Street address *

Suburb *

What is your age?

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

Gender

Female
Male

Emergency contact details:

Please provide name, relationship and telephone number

Who is your family doctor (GP)

Private health fund company?

Please give the name of the fund if applicable

Type of treatment:

Please indicate the type of treatment that you are interested in (you can select multiple items)

Whole body massage
Specific area massage

Remedial massage
Sports massage
Deep tissue massage

Relaxation massage
Stress relief massage
Hawaiian Lomi Lomi massage
Hot stone massage

Lymphatic drainage massage
Post liposuction treatment

Your massage appointment:
For post surgery appointments (lymphatic drainage, scar tissue treatment etc.) please skip to the next section

Reason for booking a massage

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

Are you making an appointment for treatment for specific area(s) or whole body?

Specific area(s) of my body
Whole body treatment
Whole body with extra work on specific area listed above

Trauma details

Have you suffered an injury that prompted the booking?

How long have you been in pain?

Pain severity

0=no pain 10=extreme pain

Have you had a professional massage in the past?

Use this section for post surgery appointments (post liposuction, tummy tuck etc.)
(For remedial massage appointments please skip this section)

Have you recently undergone a surgical procedure?

Name of clinic where your treatment was performed

Name of clinic or doctor’s name

Date of your surgery?

Do you have the dates of any follow up appointments with the clinic?

Have you booked sufficient appointments to ensure speedy recovery?

Yes I have booked the minimum 6 appointments over 3 weeks
No but I will
I will book later and take a chance on availability

Minimum 6 appointments over 3 weeks

Have you read the Lipo information page on the Fitnwell website?

Yes
No but I will
No

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

What is your occupation?

How physical is your job?

Not physical
Moderately physical
Very physical

How would you rate the level of stress that you experience from your job?

Not much stress at all
Moderately stressful
Very stressful

Recreational activities or sports

Please list

Conditions

Regular medications?

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

Please give details

Please explain further

Are you pregnant?

If YES how many weeks?

Do you take blood thinning medications like aspirin, warfarin etc.

Do you bruise easily if you bump into objects?

General

Any questions or concerns?

How did you find out about FitnWell Massage?

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

Consent to provide treatment

…

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

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

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