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Luna's Moon Client Intake Form

About You....

What is your First Name?

What is your Surname?

What is your Home Address?

Email address

Phone number

What is your relationship to baby?

Do you have any allergies?

Do you have any medical issues which will prevent you from sitting on the floor to do the massage or light movements?

Do you have any medical issues which will prevent you from sitting on the floor to do the massage or light movements?
A
B

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?
A
B

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 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 from the floor.

About baby....

Baby's Full Name

What is Baby's Date Of Birth?

Baby's Gender?

Baby's Gender?
A
B

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?
A
B

Please list all known medical conditions, otherwise state none.

*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.*
*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

Disclaimers....

Please review all the information you have provided carefully before submitting the form.
If you have any questions or concerns, please contact us for assistance.

I confirm that the information I have provided is honest and is to the best of my knowledge and have sought any medical advice if required, before I attend the baby massage classes.

I confirm that the information I have provided is honest and is to the best of my knowledge and have sought any medical advice if required, before I attend the baby massage 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.

Programme Booking Details

Preferred programme start date -

6-week Baby Massage programme:
Preferred programme start date -

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 payment sent, form submission and to agree for Luna's Moon to process and store your personal information for class attendance and health & safety purposes only!

Signature
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