Client Intake & Consent – Whitewood Wellness

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Client Information

Clinic Location

Shop 4, 39 East Esplanade, Manly NSW 2095 GF 637 Darling St, Rozelle NSW 2039 1C/27-29 Burwood Rd, Burwood NSW 2134

Full Name

Date of Birth

Phone

Email

Emergency Contact

Contact Phone

Private Health Insurance Company

Membership No

Claim Method

HICAPS Self Claim No Claim

Health Information

Are you currently taking any medications?

Yes No

If yes

Any allergies? (oils, lotions, nuts, fruits, skin products, etc.)

Yes No

If yes

Are you currently pregnant?

Yes No

Weeks Pregnant

Due Date

Areas of broken skin? (e.g. rash, wounds)

Yes No

If yes

Under medical supervision or treatment?

Yes No

If yes

Recent injuries or surgery within past 2 years?

Yes No

If yes

Please tick any conditions that apply:

Other Medical Conditions

Reason for Treatment

Injury Recovery Pain Relief Stress Relief Muscle Tension Remedial Treatment

Areas of concern / pain

Preferred Pressure

Light Medium Firm

Client Consent

Client Signature (type full name)

Date

Therapist Use Only (Store Only)

Saved to the shop database / JSON store. Not included when printing or exporting the A4 PDF.

Therapist Name

Provider Number

Treatment Date

Other Treatment

Treatment Type

Client Intake & Consent Form

WHITEWOOD WELLNESS & MASSAGE