Client Consultation Form

First name

Last name

Email

Phone

Date of Birth

Day

Month

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About Your Session

Which Treatment are you booking?

Water Mastery

Crystal Healing

Sound Meditation

Intuitive Healing

Your Health & Wellbeing

Do you currently have, or have you recently experienced, any health condition, medical treatment, surgery or other circumstances that may be relevant to your treatment?

Single choice

Yes

No

If yes please tell me a little bit more.

Please include any relevant diagnosis, treatment, recent surgery or injury

Please tick any that currently apply to you.

Are you currently taking any medication

Yes

No

If Yes, please provide the name of the medication and what it is prescribed for.

Do you have any other medical conditions or health concerns that have not been mentioned above?

Yes

No

If Yes, please provide the details.

Your Wellbeing

What has brought you to Aqualume at this time?

How would you describe how you have been feeling recently?

Is there anything you feel will be helpful for me to know before your session?

Consent & Declaration

Please read the following statements carefully before submitting your form.

I understand that Aqualume treatments are complementary wellbeing therapies and are not a substitute for medical diagnosis, advice or treatment from a qualified healthcare professional.

I confirm that the information I have provided on this form is accurate and complete to the best of my knowledge, and I will let my practitioner know if there are any changes to my health, medication or circumstances before or during future treatments.

I understand that I can ask questions at any time and may ask for the treatment to be paused or stopped at any point.

I give my informed consent to receive the Aqualume treatment I have booked.

I understand that the information provided on this form will be stored securely and used by Aqualume for the purpose of providing and managing my treatment. I have read and agree to Aqualume's Privacy Policy.

Signature

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Date

Day

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