JemmaCo Consultation Form

JemmaCo Consultation Form
Full Name *

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
DOB

Month Day Year
Date
Check the conditions that apply to you now or in the past: *

Asthma Cancer Cardiac disease Diabetes Hypertension Psychiatric disorder Epilepsy Pregnant None of above
Are you currently taking any medication? *

Yes No
Do you have any allergies? *

Yes No
What is the your main reason for treatment?
How do you wish to feel from your treatment?

Harmonised Revitalised Relaxed
Details of tension or pain areas: please specify areas on your body and the type of discomfort experiences.
For example: Sharp / Pulling / Tender / Intense / Shooting / Aching

Please select up for 3 Options to include in your massage and type in the box. If you wish to discuss with your therapist please write discuss

	Please write your requirements
Heat (Hot stone/ Warm Bamboo / Heated Pads)
Chakra Balance (Sound / Healing / Dowser)
Acupressure ( Feet or Face)

Is there anything else we should be aware of? If none leave blank
Declaration *

I agree to the above information being accurate and to the best of my knowledge.
Signature *

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