Your Name (required)

Your Address (required)

GP's comments

Notes

Notes

Most recent vaccinations (required)

Any reactions to vaccinations?

Any learning or physical needs?

Any chronic or acute health issues?

Any medication?

Contradictions
If your baby experiencing any of the following on the day of a massage class, it is important you do not attend:

Vaccination in the last 3 days, Vomiting, Skin rash, Infections, Cuts/wounds, Diarrhoea, Temperature/fever, Bruising/swelling, Inflammation

Is there anything else you would like to make me aware of?

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I confirm that the information supplied is a true record and understand that I should not massage my baby if my baby is experiencing/has experienced any of the above contraindications. I take full responsibility for the health of my child and myself in the sessions and should there be any medical changes I will consult my Instructor. I understand that I will be responsible for my child throughout the course.