Booking Form
Your name:
Address:
Post Code:
Contact number:
Your email address:
Service required:
Ctrl for multiple
selections
Treatment location:
Date required:
Time required:
Do you require more
info:
Email
 Post
Are you taking regular
Medication?:
Yes
 No
Do you have any contraindications to treatment?
This is a specific condition medical or otherwise that may prevent or constrict treatment for
example a recent operation or transmittable infection (a verruca in the treatment area eg;
foot). If so please give details below if non type NONE
Additional information/
special requirements:
Please note sending this form does not ensure a booking
Bookings will be confirmed via email or phone call, after suitable dates, times and payment
is agreed.  If you have any further questions please do not hesitate to contact me.
Price list