CITY HAVEN MASSAGE THERAPY
RESIDENT REGISTRATION FORM FOR MASSAGE THERAPY
Name of Facility: (Please Print):
Address:
Date of Application:
PERSONAL INFORMATION
RESIDENTS NAME:
LEVEL/ROOM NUMBER:
BIRTH DATE:
/
/
HOBBIES/ INTERESTS (Things they loved to do or enjoy talking about):
AGE:
PRIVATE HEALTH INSURANCE INFORMATION
PRIVATE HEALTH FUND NAME:
DOES COVER INCLUDE REMEDIAL MASSAGE ?
YES
NO
MEDICAL CONDITIONS
PLEASE TICK ALL CONDITIONS THAT APPLY TO THIS RESIDENT
Heart/Circulatory Problems
Cancer/Tumours
Vision problems
High Blood Pressure
History of Asthma or lung conditions
Low Blood Pressure
Hearing problems
Varicose Veins
Hernias
Depression
DVT
Blood clots
Seizures
Arthritis - specify type below
Stroke
Infectious Disease
Skin Disorders
Rash
Athletes Foot/Tinea
Muscle Injuries
Bone injuries
Allergies
Behavioural Concerns - specify below
PLEASE EXPLAIN FURTHER ANY CONDITIONS INDICATED ABOVE:
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PERMISSION TO GIVE ACCESS TO RESIDENT MEDICAL RECORDS
I/We give permission for City Haven Massage Therapy staff to access medical records at the nursing
home for this application.
NAME OF RESIDENT:
NAME OF PERSON GIVING PERMISSION:
DATE:
SIGNATURE:
Please Note: All resident information is kept strictly confidential at all times and only the City Haven
Massage Therapy staff assisting this resident will access their records. This ensures better
communication between medical practitioners, nursing staff and City Haven Massage Therapy
therapists. All Massages will be clinically recorded and added to the progress notes of each resident
immediately after a massage session.
FREQUENCY AND DURATION OF MASSAGE THERAPY
PLEASE INDICATE HOW OFTEN YOU WISH TO BOOK MASSAGE FOR THIS RESIDENT:
WEEKLY
30 MINS - $55.00 INCL GST
FORTNIGHTLY
45 MINS - $66.00 INCL GST
MONTLY
60 MINS - $77.00 INCL GST
GP APPROVAL
NAME OF GENERAL PRACTITIONER:
ADDRESS:
TELEPHONE:
DO YOU APPROVE REMEDIAL MASSAGE ?
YES
PLEASE DETAIL ANY CONTRAINDICATIONS OR CAUTIONS:
NO
GP Signature:
NEXT OF KIN INFORMATION
NAME:
ADDRESS:
CONTACT PHONE:
WOULD YOU LIKE INVOICES SENT TO YOU?
YES
NO
Email address to send invoices:
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PAYMENT INFORMATION
An invoice will be sent out at the end of each month. Please indicate how you wish to pay by ticking the
appropriate box below. If you would like us to charge your credit card at the end of each month, please
authorise us to do so below.
CHEQUE
Please make cheques payable to 'City Haven Massage Therapy'
BANK DEPOSIT Westpac: BSB: 033 039 Account: 560209 Name: City Haven Massage Therapy
CREDIT CARD
Name on Card:
Type of Card:
Visa
Mastercard
Credit Card Number: ____ / ____ / ____ / ____
Expiry: __ / __
Signature:
Postal Address:
City Haven Massage Therapy
P.O. Box 447
Camberwell VIC 3124
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