Tynemouth's premier chiropractic care facility

New Patient history: Massage therapy 

Please fill in as much of this form as you can and tick where appropriate.

Areas marked with * must be filled in.

Full name:*






Address:






Email: *






Mobile:






Home phone:

HEALTH - do you suffer from any of the following? 

If so please describe briefly.

BOOK an appointment
to see our massage therapists
here 

Are you pregnant?


Heart condition?






Blood pressure: high/low






Epilepsy or Diabetes






Respiratory disorders






Circulatory disorders, eg, fluid
retention, kidney, varicose veins

Skin sensitivity 

Allergies

Do you suffer with arthritis,
joint or muscular problems

Other medical problems


Taking any medication?

Lifestyle


Occupation






Active or sedentary

Exercise

Do you smoke?






Alcohol consumption






Your aims from this treatment?






I understand that this treatment is taken at my own risk and that neither Michael Cooper/Push Fitness nor Wayne Dobson/High Tide Adventure Co. will assume liability of any kind. I have answered the questions to the best of my knowledge and will undertake to inform you of any alteration to the above.


Push Fitness/High Tide Adventure Co are independently operated companies
and Naturally Chiropractic cannot be held liable, financially or legally for 

Push Fitness/High Tide Adventure Co.


Please note that by submitting this form you are giving us permission to contact you using the methods listed above. Your details will be held on the Naturally Chiropractic database on behalf of Push Fitness and/or High Tide Adventure Co. but will not be passed to third parties at any other time. You will be added to our email newsletter, which will keep you appraised of events and important information.

You can unsubscribe at any time.



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Naturally Chiropractic:  1a St Oswins Place, Tynemouth NE30 4RQ

t: 0191 259 6777  | e: info@naturallychiropractic.co.uk