Therapy Request Form

Holistic Therapies Enquiry Form

Magenta Therapy
Name*

First NameLast Name
Email address
example@example.com
Contact number (mobile preferred)
Please briefly describe your reasons for requesting a treatment today, e.g. health problems, relaxation, mental well-being*
Have you had any Covid19 vaccines? You will need to leave 2 weeks after a vaccination before coming for your treatment.*
Do you have any of the following? These are contraindications and may affect your ability to receive a treatment at this time.*

Deep Vein ThrombosisPulmonary EmbolismCellulitisNotifiable Disease diagnosis, including Covid 19Unstable medical conditionImminent medical testsNone of these apply
NOTE: Please do not attend your therapy session if you have any current or recent symptoms of contagious illnesses e.g. respiratory, gastro-intestinal, viral. As a rule, 24 hours notice is required for cancellations or a fee may be charged, at the therapist's discretion.
Please give an indication of your availability for appointments e.g. daytimes, weekends, evenings*
Where did you find out about me?
A full consultation will take place at your first appointment but if there is any other information you think you need to give, please type it below.
Thank you for completing the form. I will be in touch shortly. Marie
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Holistic Therapies Enquiry Form