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Your Full Name

Date of Birth

Contact Number

Home Address

Postcode

Please provide further details here of your health conditions

I am interested in the following treatments(required)

Massage Reiki Facials Distant Reiki

In addition to my phone and email, I am happy to be contacted by

Facebook / Messenger

Your ideal setting (room temperature, ambience, couch, cushions etc)(required)

I am happy with aroma diffusers and incense fragrances Cool and Breezy (approx 15c-18c) Warm and Comfortable (18c-23c) Thermals as I freeze so easily (24c-27c) I am less than 22 stone / 140 kg / 308 lbs I am over 22 stone / 140 kg / 308 lbs (Table Limitation) I have a physical limitation (eg. unable to lie on front or back or sides for a long duration)

Appointments I can take...(required)

Mon - Fri (mornings - afternoon) Mon - Fri (afternoons - evenings) Sat & Sun (afternoon- early evening)

Any other information you feel is relevant in preparing for your appointment

I am happy for my therapist to explain the benefits of the treatment at my booking and possible side effects which may occur as a result, I understand that my therapist cannot diagnose any health condition

I agree and understand that this is professional complementary therapy and does not substitute or replace for medical or counselling needs. I recognise that my participation is voluntary and that I’m happy to proceed. I have read and understand the Cancellation Policy

Disclaimer: All the information I have given is accurate and correct and I have not withheld any information about my health. I will keep my therapist informed of any changes regarding my health in future**

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