Your Email Address:                    

                                 Full Name:                                  

       Company Name (If Applicable):     

                     Address:                      

Comments, details or questions?

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                    Appointment Date:                       

                      Appointment Time:                       

                         Telephone (WK):                          

                       Telephone (MB):                         

                         Telephone (Fax):                          

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Only complete below details for your first treatment (This is a one-off procedure upon initial consultation)

Have you had a treatment for you condition previously?

NA Yes No
 

What is your choice of therapy

Not sure? Chinese Massage Remedial Massage Swedish Massage Therapeutic Massage (Recovering from injury) Acupuncture Chinese Herbs Chinese Exercise Chinese Beauty Treatment

Are you currently taking medication? NA No Yes

Please list previous treatment for injury or any medication (if applicable)

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Do you have any medical conditions presented below (Please tick box):