New Client Massage Form

New Massage Clients only

If you're a returning client you do not need to complete this form.

If you're new to nourishe please fill in as much detail as you can.

All information provided will enable me to tailor your massage to suit your needs.

All details remain confidential.

A deposit is required to secure your booking.
Todays Date

Day Month Year
Date
Name *

First Name Last Name
email *
Date of Birth

Day Month Year
cellphone:

Area Code Phone Number
landline:

Area Code Phone Number
Address: *

Street Address

Street Address Line 2

City

Postal / Zip Code Country
Occupation *
How did you hear about nourishe? *
Woluld you like to receive my monthly @nourishe newsletter? *

No Yes
Within the last 6-12 months have you had/done any of the following:

Overseas Travel Surgery Serious Illness Trauma or Injury Pregnant or recent Pregnancy Covid-19
Please add any other relevant info or concerns you may have
Current Medical or Complementary Treatment *
Please include Homeopathic, Herbal, Vitamins and any other treatment providers you are currently working with
EXERCISE *

Highly active (exercise 5+ times per week) Moderately active (exercise 3-5 times per week) Less active (exercise less than 3 time sper week) Inactive
Please provide more details (type of exercise, time of day etc):
What is your main reason for booking a massage today? *
Informed Consent:

I agree that I will be fully informed about my treatment and have all my questions answered to my satisfaction. I consent to a physical assessment (if needed) and treatment plan as explained to me by Deborah Wright (practitioner).

I understand that if I am unhappy with the treatment provided I can in the first instance address this with Deborah Wright (practitioner). Alternatively I can contact an independent Health and Disability Advocate by phoning (04) 494 7900.
I have read & agree with the above INFORMED CONSENT.
First Name* Last Name*

My Products

Massage Booking - deposit $ 45.00

Thanks for booking. A $45 deposit is required to confirm your appointment.

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Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

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