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 

Heart condition?

Blood pressure: high/low

Epilepsy or Diabetes

Respiratory disorders

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

Skin sensitivity 

Allergies

Taking any medication?

Lifestyle

Occupation

Active or sedentary

Exercise

Your aims from this treatment?

I understand that this treatment is taken at my own risk and that neither Naturally Chiropractic nor our resident professional therapists 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.

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 our therapists but will not be passed to third parties at any other time. You will also be added to our email newsletter, which will keep you appraised of events and important information.
You can unsubscribe at any time.