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Baby Massage Enrollment Form



    fields marked with * are required

    Parents name*

    Address *

    Telephone number*

    Mobile number


    Baby's name*

    Date of birth*

    Does your baby currently have any of the following: (please tick)

    Bruising on hands or arms?* yesno
    Cuts and abrasions?* yesno
    Skin conditions* yesno
    Undiagnosed lump or swellings?* yesno
    Muscular or joint problems/fracture?* yesno
    Allergies to oils/lotions?* yesno
    Any other health problems/concerns?* yesno


    I have completed the form as fully and as accurately as I can. I believe the details on this form to be correct and consent to having treatment with the practitioner detailed on the form. I release the practitioner from any neglect misrepresentation that may be contained on this form. I accept the Agape Wellbeing privacy terms and conditions: Privacy Notice


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