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(03) 9043 9742
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About us
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Contact us
(03) 9043 9742
Home
About us
Health Fund Rebates
Client Confidential Information
Treatments
Price & Promotions
Our Gift Vouchers
Contact us
book an appointment
Client Confidential Information
Lelux Thai Massage
Client Confidential Information
Your Health Fund:
Membership Number:
What number are you listed on the card? Patient ID:
Date of Birth
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Name:
*
Surname:
M/F
Address:
Postcode:
Email:
Phone/Mobile
Occupation:
Regular Sport/Activities:
How did you find us? True Local/ Internet/Google/Website/Passing by/ Word of mouth/ Flyer/ Facebook/ Gift voucher/ Referred by:
Please tick all conditions that apply
Stroke
Cancer
Migraine
Headache
Heart Conditions
Pain/Stiffness
High/Low Blood Pressure (on medication)
Broken/Dislocated Bones/Muscles/Joints
Contagious/Infections Diseases
Pregnancy
Neck
Lower Back
Mid Back
Upper Back
Shoulders
Hip
Other
Pregnancy/How Many Weeks?
*
Are there any other conditions that may affect the treatment or Any recent injury/accident?
Emergency contact name and phone number:
*
Massage Practitioners are not qualified to diagnose or treat illness or to perform manipulation. Massage does not take the place of medical treatment where needed. If you are in doubt, please consult your doctor.
Terms and Condition
*
I agree to the treatment/ongoing treatment at Leluxthai Massage in accordance with Lelux policies.
Signed:
Date:
DD slash MM slash YYYY
HEALTH FUND REBATES
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OUR GIFT VOUCHERS
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Treatment Name
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