Registration and indemnity form

1

Hello, what is your name?* This field is required.

First Name

Last Name

2

Nice to meet you {helloWhat:first}, what is your email address so we can get back to you?* This field is required.

example@example.com

3

If we need to call you {helloWhat}, where can we reach you?* This field is required.

Please enter a valid phone number.

4

{helloWhat:first}, tell us all about your little bundle of joy. What is his/her name?* This field is required.

First Name

Last Name

5

What is {hellowhatfirstTell:first}'s gender?* This field is required.

6

What is {hellowhatfirstTell:first}'s date of birth?* This field is required.

Date

7

How much does {hellowhatfirstTell:first} currently weigh(kg)? * This field is required.

8

At how many weeks was {hellowhatfirstTell:first} born?

9

What was {hellowhatfirstTell:first}'s weight(kg) at birth?

10

Please give us the name of your next of kin.* This field is required.

First Name

Last Name

11

If we need to reach them, which number should we use?* This field is required.

Please enter a valid phone number.

12

Where did you hear about us?

13

Would you like to join our mailing list to be the first to hear about promotions and specials?

YESNO

14

Has {hellowhatfirstTell:first} been diagnosed with any medical conditions that you are aware of?* This field is required.

YESNO

15

What condition has your baby been diagnosed with?

16

Does your baby struggle with any of the following:

17

Has your {hellowhatfirstTell:first} undergone any form of surgery?* This field is required.

YESNO

18

Have you been referred by a Health Care professional?

YESNO

19

Do we have consent to take photos of {hellowhatfirstTell:first} enjoying his/her thrpy. session?* This field is required.We use the photos taken on our official thrpy Instagram & Facebook platforms as a testimony to other moms and babies. Photos taken will be shared with you shortly after your session via WhatsApp. If you are uncomfortable with this, please indicate 'No'. If you are comfortable with this, please indicate 'Yes'.

YESNO