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Ear Candling Form
Ear Candling Record
You Yangs Massage clients are required to complete this form before being treated.
Step
1
of
4
- Contact Details
0%
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Contact Phone
*
Email
*
Occupation
Date of Birth
*
Day
Month
Year
Emergency Contact Details
*
First
Last
Emergency Contact Phone
*
Pregnant (Women Only)
Yes
No
If you are pregnant you are required to fill out the Pregnancy Form instead of this form. Use the main menu or
CLICK HERE
to access the Pregnancy Form. There is no need to fill this form out if you fill out the Pregnancy Form.
Injuries / Accidents / Operations
Sport / Exercise Activity
Allergies
Vision / Hearing Impairment
Have you ever had professional ear candling before?
Yes
No
Referred by
Do you have an Ambulance Subscription?
Yes
No
Health Fund
Do you suffer from any medical conditions?
*
Yes
No
Asthma or any other respiratory condition?
Yes
No
High blood pressure?
Yes
No
Osteoporosis?
Yes
No
Arthritis?
Yes
No
Epilepsy?
Yes
No
Cardiac/Heart Problems?
Yes
No
Digestive Complaints?
Yes
No
Tumours?
Yes
No
Diabetes?
Yes
No
Cancer?
Yes
No
Thrombosis?
Yes
No
Haemophilia?
Yes
No
Other (please state)
Medication
Can you confirm that all details on this form are correct at this time?
*
Yes
No
Would you like to receive specials or reminders via email?
*
Yes
No
Please tick that you have read our cancellation policy
*
Please call by 10 am on the day prior to your scheduled appointment to notify of any changes or cancellations. To cancel a Monday appointment, please call by 10 am on Friday. Cancellation fee may apply if no prior notification given.
Read Policy
I understand the cancellation policy terms
Signature
*
Any other comment?
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