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:

Please tell us your height and weight

BOOK an appointment
to see Michael:

2025 schedule to be confirmed.

HEALTH - do you suffer from any of the following? 

If so please describe briefly.

Heart condition?

Blood pressure: high/low

Epilepsy or Diabetes

Respiratory disorders

Allergies

Taking any medication?

Lifestyle

Occupation

Active or sedentary

Exercise

Do you smoke?

Alcohol consumption

I understand that this treatment is taken at my own risk and Michael Cooper/Push Fitness will assume no 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 is an independently operated company and Naturally 

Chiropractic cannot be held liable, financially or legally for Push Fitness.

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 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.