New Client Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth (DD/MM/YYYY) *Address *Contact Number *Email *Emergency Contact – Name, Relationship & Contact Number *Which services are you booking: *MassageReikiOtherHave you had a professional Massage/Reiki before? *Yes, recentlyYes, over 12 months agoNoPreferred Massage pressure: *LightMediumFirmAre there any areas (feet, face, hands, abdomen, etc.) that you do not want massagedGoals for this treatment session, e.g., relieve pain in lower back, relax. *Please tick any current medical conditions or considerations that apply *CancerDepression/AnxietyHeadache/MigranesHigh/Low blood pressureDiabeties – Please provide details in the fiels belowSprains/Strain – Please provide details in field belowStroke/Heart Attack – Please provide details in field belowCurrently Pregnant – Please provide details in the field belowArthritis/Joint Replacement – Please provide details in field belowAllergies/Medications/Other – Please provide details in field belowBlood Clots – Please contact the studio prior to your treatment to discussNeuropathy/Numbness/Fibromyalgia – Please provide details in field belowI confirm I have no medical conditions, or allergiesIf you have selected any conditions above, provide details:Advise if you have clearance form your doctor for this service: *I can confirm that I have clearance from my doctor or specialistI do not have clearance – please contact Total Wellness Co ASAPN/AHow did you hear about us?InternetSocial MediaWord of mouthOtherTotal Wellness Co Policy and Client Agreement *I understand that this service does not diagnose and heal illness, disease, any physical or mental disorder. I acknowledge that this is not a substitute for medical examination or diagnosis, and it is recommended that a relevant medical practitioner be seen for that service. I confirm I have stated all medical conditions, and will update Total Wellness Co of any changes in my health status as soon as they occur, or within 24 hours of my next treatment session.I understand it is my responsibility to be on time to my appointment and that the full service fee will be payable should my session need to be shortened due to the late arrival. Cancellations or rescheduling made less than 24 hours before the scheduled appointment time will be subject to a cancellation fee. The cancellation fee will be 50% of the service fee. Failure to cancel or reschedule 24 hours before the appointment results in full service fees. To cancel or reschedule an appointment, please text Tarnya at 0428310933.I understand that Total Wellness Co has a Zero tolerance policy for sexual or inappropriate behavior of any kind and accept that my treatments will be terminated without refund should I choose not to respect this policy.I confirm that I agree to Total Wellness Co Policy and Client Agreement via the electronic signature below *FirstLastSignature Date (DD/MM/YY) *Submit
