The Eventide Glow Consultation Form

First Name

Last Name

Date of Birth

Address

Contact Number

Emergency Contact Name

Emergency Contact Number

Are you currently taking any medication?

Yes

Please specify (Medication)

Do you have any medical conditions?

Yes

Please specify (Conditions)

Are you currently, or possibly may be, pregnant?

Yes

Do you have any allergies or intolerances?

Yes

Please specify (Allergies/Intolerances)

Are there any ingredients you won’t eat?

Yes

Please specify (Ingredients you won’t eat)

Wellness Session

Please choose one

I accept that any treatment(s) I receive at the sanctuary is at my own risk.
I certify that I have read and fully understood and completed this form to the best of my knowledge.
I understand that failure to disclose information requested above may result in adverse side effect(s) from treatment(s) received and therefore I accept full liability/responsibility for the information given.
The treatment(s) and possible side effect(s) have been fully explained to me.
I accept that if I am not satisfied with the treatment(s), I will inform the therapist and/or request to speak to the manager during or immediately following the treatment(s).
I take full responsibility for my body and behavior and consent to release and indemnify staff and any claims or injuries associated with this or any future treatment(s).
I fully understand the above and consent to receive a wellness session.

I have read and agree to the consent above

I agree

I agree to receive product information and promotions

Yes

Signature

Date

If you are human, leave this field blank.