New Client Form

Please complete the form below before attending your first treatment. Once submitted, a copy will be emailed to our clinic and a second copy will be sent to you for your records via the email you enter in the form below. We follow a strict privacy policy and your details will remain confidential – for more info please see here.

Please Note: Fields with a “**” are mandatory.

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Age
Mobile Number*
Phone number (secondary)
Address*
Street Address City State / Province / Region Post Code Country
Email address*
Enter Email Confirm Email
Emergency Contact*
How did you hear about us?
Word of mouth
Health Fund
Occupation
How many hours and what sort of physical activity do you engage in a week?
Clinic communication
Our booking system automatically sends you email and SMS reminders 24 hours before your appointment. If you tick the following, we will manually unsubscribe you from these reminder options:
Consent
I DO want to receive email appointment reminders
Consent
I DO NOT want to receive email appointment reminders
Subscriptions
We send email newsletters out to our clients every few months with updates, deals, and clinic events and news. Our newsletter management system will automatically send you an opt-in email when you first book with us. If you don't want to receive any email marketing communication from us, simply opt-out or take no action - however we hope you opt-in as we love getting client feedback and comments on our news and events.
All about your massage experience:
Have you ever experienced a massage before?*
** Have you ever experienced a massage before?
- Yes
- No
How often do you have a massage?
How often do you have a massage?
What type of touch do you prefer?
What type of touch do you prefer?
- Light/meditative
- Heavy/Invigorating
- Deep/Trigger points
Reason for seeking a massage?*
When did the symptoms start?
Is there anything that improves your symptoms?
Is there anything that makes them worse?
Have you tried any treatments before trying a massage? If so, what was the result?
Previous and ongoing treatments
If you are being treated by any other health professionals for these symptoms or related conditions, please provide their details:
Health Professional details
Health Professional 1
Name Profession Clinic Name
Health Professional details
Health Professional 2
Name Profession Clinic Name
Health Professional details
Health Professional 3
Name Profession Clinic Name
Consent
I give permission for my Remedial Therapist to consult with the above health professionals regarding my health/treatment if required
Consent
I DO NOT give permission for my Remedial Therapist to consult with the above health professionals regarding my health/treatment if required
Your general health and medical conditions:
Please select any of the conditions that apply to you
Do you suffer from any of the following symptoms?
- Allergies
- Arthritis
- Asthma
- Back problems
- Blood clots
- Breathing difficulties
- Bruising
- Cancer
- Chronic pain
- Cramping
- Depression
- Diabetes
- Disc problems
- Digestive problems
- Epilepsy
- Fatigue
- Headaches
- Heart conditions
- Hernias
- Hearing difficulties
- High/low blood pressure
- Infectious condition
- Inflammation
- Insomnia
- Joint problems
- Numbness/tingling
- Memory loss/ confusion
- Pregnancy
- Prosthesis
- Sciatica
- Sinus problems
- Skin problems
- Stroke
- Ticklish
- Varicose/spider veins
- Other not specifies in list
Please write any relevant details
How is your general health (e.g. sleeping, immunity, digestion etc)?
Please list any medication, vitamins and supplements you take regularly:
Your acknowledgement
Please read and tick each item to signify your understanding and consent to our terms of treatment. Submitting a completed form indicates your agreement. If you do not understand or agree, please do not submit this form, please contact us and ask to speak to your therapist, or wait to check with them at your appointment date (if so, please arrive 15 minutes early to fill in a hard copy of this form).
I understand*
** My remedial massage therapist will observe, palpate and then treat each part of my body with my verbal consent after explaining the rationale for each treatment.
I understand*
** This treatment does not replace medical care and your therapist is not able to diagnose or treat any illness/conditions.
I understand*
** I am responsible for advising my therapist of all medical information, current symptoms and updates to my medical history at each attendance to enable the therapist to formulate an appropriate treatment plan.
I understand*
** I am aware that if I give less than 24 hours notice for cancellation or appointment reschedule, the treatment fee will apply unless the appointment is otherwise filled and / or my therapist opts to waive the fee (please speak directly to your therapist about this if short notice cancellation occurs). No shows will be charged treatment fee regardless.
I understand*
** Niggles & Knots has a strict confidentiality policy, and will not share my health or contact details to any other person or company without my express permission. My records will be kept securely by N&K and only viewed by any staff member where necessary for my treatment. By booking an appointment with a therapist, I am implicitly giving them permission to review the information on this form, any other information I provide to N&K about myself, and any file notes other therapists have made about prior treatments.
I understand*
** Any discount my therapist opts to provide me for any treatment is not indicative of on-going treatment pricing and I will refer to the standard price list for future treatment charge rates

New Client Form

Clinic communication

Subscriptions

All about your massage experience:

Previous and ongoing treatments

Your general health and medical conditions:

Your acknowledgement