Emma West Therapy

Membership Sign up Form
All information will be kept strictly confidential and will not be shared to any other person or agency.

Please complete the form and click Submit at the bottom of page once completed.
Personal Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Date of Birth
Phone number
Phone Number*
E-mail
example@example.com
You are signing up for a Membership Programme with Emma West Therapy! Please choose which option you would like:

Tier 1 RELAXATION ESSENTIALS - 1 treatment per month £54Tier 2 WELLNESS PLUS - 2 treatments per month £104Tier 3 LUXURY - 3 treatments per month £152Tier 4 ULTIMATE REJUVENATION 4 treatments per mth £198
Which month would you like your membership to start?

1 February 20251 March 20251 April 20251 May 20251 June 20251 July 20251 August 20251 September 20251 October 20251 November 20251 December 2025
Please read the statements below, tick and sign in the box.

I acknowledge that all by completing this form I agree to set up a monthly standing order from my bank account commencing on the date indicated above for the amount indicated aboveI understand that I can join once per year. I can pause my membership once per year. I can cancel my membership at any time, giving 1 month's notice (only 1 cancellation per year)I understand that I must book my own treatment appointments every monthI understand that any massage credits can rollover for 1 year after which they will expire. There is a no refund policy for unused credits.I understand that any massage credits can be transferred to my family or friendsI understand if I do not show up for an appointment I may be charged 50% of the fee (there are exceptions for emergencies)
Date

MonthDayYear
Date
Signed (type name)

First NameLast Name
Phone Number
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