Soulstice Consultation Form
Client Name
First Name
Last Name
Phone Number
*
Please enter your mobile number omitting the 0
Format: (000) 000-0000.
Email Address
*
example@example.com
Are you booking a Gong Sound Bath?
Yes
No
Not suitable if you have a heart condition, pacemaker or pregnancy
Are you booking a Treatment?
Yes
No
Check the following if any of them applies for you.
Pregnancy
Breast feeding
Cancer Treatments
Pace Maker
High Blood Pressure
Low Blood Pressure
Heart Condition
Neurological Concerns
NA
Any known Allergies
Are you taking any medication?
*
Yes
No
Please give details or add NA if not applicable
*
What would you like to achieve from todays Treatment / Experience?
*
An example might be - Relaxation
Date
-
Day
-
Month
Year
Date
Client's Signature
Therapist Name
First Name
Last Name
Therapist's Signature
Save
Submit
Submit
Should be Empty: