Please complete the new patient intake form and click Submit to send the details to reception.

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Patient Details
Date of birth

Medical History
Work Cover/Third Party Insurance Contact Details (if applicable)
Please read and agree to the informed consent


The law requires all practitioners who manipulate the spine to warn patients of material risks. In extremely rare circumstances, some treatments of the neck may damage a blood vessel and give rise to stroke or stroke-like symptoms (approx. 1 in 5.85 million neck manipulations) [Haldeman, et al. Spine vol. 24-28 1999.] Whilst this has never occurred in this practice, we are still required to warn. If any adjustments (manipulations) are required, you will be tested beforehand, as has always been our practice. Other slight risks include strain/injury to a ligament or disc in the neck (less than 1 in 139,000) or the lower back (1 in 62,000). [Dvorak study in Principals and Practice of Chiropractic, Haldeman, 2nd Ed.]

Chiropractic Adjustments (manipulations) of the spine are internationally recognised as being far safer in dealing with neck and lower back pain than medications and many other alternatives. (A Risk Assessment of Cervical Manipulation, JMPT, 1995. Manga Report, Ontario Ministry of Health, 1993.) The procedures to be used in your case will be clearly described to you. You are encouraged to ask questions and raise any concerns you might have about chiropractic care. After speaking with the chiropractor we request that you sign below, as your consent to proceed is required. Please note that there may be a considerable degree of variation in individual patient response.


I, (Client’s Name) have chosen to consult with and hereby give consent for massage therapy to be provided by (Therapist’s name) who I understand is a member of a registered Massage Association. I have provided a detailed medical history. I do not expect the therapist to have foreseen any previous or pre-existing condition that I have not mentioned. I understand that massage may provide benefits for certain conditions but results are not guaranteed. These benefits may include relief of muscular tension, relaxation, reduction in the symptoms of stress related conditions and provision of general wellbeing. I also understand that massage therapy may produce side effects such as muscle soreness, mild bruising,increased awareness of areas of pain and light-headedness amongst other possible temporary outcomes. I am aware that the therapist does not diagnose illnesses, prescribe medications nor physically manipulate the spine or its immediate articulations.The therapist understands that I have the right to question procedures used and to receive an explanation of any procedures that the therapist performs. I will tell the therapist about any discomfort I may experience during the therapy session and understand that the therapy will be adjusted accordingly.

Cancellation Policy

We understand that life can take you into unexpected turns, but if you cannot make your appointment time, please call and inform us as soon as possible.
 At least 24 hours notice is appreciated.  This gives patients on our waiting list an opportunity to book in. 
Thank you for your understanding. 

Missed/Cancelled appointments without appropriate notice will be charged in the following way.
  • Once is accepted without charge, but please ensure you reschedule appropriately where your appointment will hopefully not be impacted.
  • On a second missed appointment we request that you pay half of the fee.
  • On a third missed appointment we will request a full fee rate for that time andfuture appointments will have to be made on the day you wish to come in.
I have read and agree