Mirage Bodywork Intake Form

Mirage Bodywork Consent Form

Please fill out before your scheduled time slot
Full Name:
Mobile:
D.O.B

DayMonthYear
Email:
example@example.com
Home Address (Including Suburb):
Do you exercise at least weekly?
Reason for consultation:
Medical/Trauma history:
Previous treatment:
Affected areas:

Other
Medications:
I hereby consent to a consultation and/or therapeutic treatment inluding but not limited to postural analysis, chair massage, and/or the use of kinesiology tape. These treatments may lead to tenderness. I will ask my practitioner for further details about these if required.

Mirage Bodywork respects your privacy, and never shares information. I understand and accept these terms, and give Mirage Bodywork LLC permission to possess my above information, and to treatment my body therapeutically.
Signed
Date:

DayMonthYear
Should be Empty: