MASSAGE THERAPY REFERRAL FORM

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2

We aim to provide a tailored care plan, please provide as much details as possible. Note that all information will remain strictly confidential.

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Referring Agency/Person* This field is required.

Name

Agency/Relationship

Phone

Email

Date of referral

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Client Details* This field is required.

Name

D.O.B

Gender

Country of Birth

Residential Adress

Phone

Email

5

Does the client identify as Aboriginal and/or Torres Strait Islander origin?

Yes

No

Prefer not to say

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Next of Kin

Name

Relationship

Phone

Email

7

What is the current living arrangement? (Live alone, with partner etc.)

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Are there any stairs to access the client's home?

Yes

No

Not sure

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Recommended or desired frequency for massage therapy

Weekly

Fortnightly

Monthly

Not sure

11

Preferences for massage therapists?

Female

Male

No preferences

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Please list any current medications the client is taking e.g. Pain relief, blood thinners, corticosteroids.

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Treating Doctor

Name

Practice

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Is the client under the care of an allied health professional?

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Use of mobility aids?

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Does the client have mobility issues that would restrict them from receiving treatment on a massage table?

Yes

No

Not sure

18

Is there a risk of falls for this client?

Yes

No

Not sure

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Anything else that would help us understand the client's care requirement?

20

Thank you for reaching out to Remedial Therapy at Home

We will get back to you shortly

If you have any querries, please do not hesitate to contact us

📩 info@remedialtherapyathome.com

📞 0435 350 789

🌐 www.remedialtherapyathome.com

📫 PO Box 162 Elizabeth St, North Hobart, TAS, 7002

📍 Hobart, Launceston, Devonport - Tasmania