🌙Luna's Moon Client Intake Form
What is your relationship to baby?
*
✨A bit about your health:
Do you have any allergies?
*
Do you have any allergies?
Do you have any medical issues which will prevent you from sitting on the
floor to do baby massage or light movements?
Do you have any medical issues which will prevent you from sitting on the
floor to do baby massage or light movements?
Do you have any back pain or find it difficult to sit for extended periods of time?
*
Do you have any back pain or find it difficult to sit for extended periods of time?
Do you have any mobility issues? Please tell us below. If none, please state none.
*
I confirm that I am fit and healthy and do not have any conditions which will prevent me from
doing moving/stretching, sitting or getting up or down from the floor.
*
I confirm that I am fit and healthy and do not have any conditions which will prevent me from
doing moving/stretching, sitting or getting up or down from the floor.
What is Baby's Date Of Birth?
*
Does baby live at the same address as you stated above? If no, please provide below otherwise state - as above:
*
Number of weeks gestation baby was delivered at
*
Does baby have any known allergies or sensitivities that you know of? Please list below
*
Does baby have any health issues?
*
Does baby have any health issues?
Please list all known medical conditions, otherwise state - None known.
*
*If yes was ticked to baby having known health issues -
*
I have sought medical advice from my GP for my baby (named above) to attend baby
Massage and I have been advised by a qualified medical practitioner that it is safe for us to do so.*
*If yes was ticked to baby having known health issues -
What are your goals or expectations for the massage sessions?
*
Has your baby received massage therapy before?
*
Has your baby received massage therapy before?
Are there any cultural factors that should be considered?
*
✨Emergency Contact Details....
Emergency Contact First Name
*
Emergency Contact Surname
*
Emergency Contact Phone Number *
*
Emergency Contact's relationship to you/baby
*
Please review all the information you have provided carefully before submitting the form.
If you have any questions or concerns, please contact me for assistance.
I confirm that the information I have provided is honest and to the best of my knowledge, and I confirm that I have sought medical advice if required, before I attend the classes.
*
I confirm that the information I have provided is honest and to the best of my knowledge, and I confirm that I have sought medical advice if required, before I attend the classes.
I confirm that I am happy for me and my baby to use the Organic Cold-pressed Grapeseed oil the instructor provides, and will complete a patch test in the first class and inform the instructor of any allergies, should they arise.
*
I confirm I am doing this at my own risk and do not know of any allergies for me or my baby, to this ingredient already.
I confirm that I am happy for me and my baby to use the Organic Cold-pressed Grapeseed oil the instructor provides, and will complete a patch test in the first class and inform the instructor of any allergies, should they arise.
6-week Baby Massage programme on Tuesdays 10:30 - 11:45 on the dates shown below.
*
Please choose your preferred date(s):
6-week Baby Massage programme on Tuesdays 10:30 - 11:45 on the dates shown below.
Where did you hear about Luna's Moon?
*
Is there anything else you feel Luna's Moon should be made aware of about you or your baby?
*
I give permission for Luna's Moon to take photos of my baby and I for use on their website and social media, and to share with me for involvement in the classes
*
I give permission for Luna's Moon to take photos of my baby and I for use on their website and social media, and to share with me for involvement in the classes
Sign to confirm form submission and to agree for Luna's Moon to process and store your personal information for class attendance and health & safety purposes only!
*
Please use the link below to make payment for your chosen class before form submission:
6-week Baby Massage Programme - £65
https://pay.sumup.com/b2c/QMGEXUUK 6-week Mum & Baby Yoga, Movement & stretch Programme - £65
https://pay.sumup.com/b2c/QA5980T8
