Name *

First Name

Last Name

Please tick any of the criteria you meet below *

Under the age of 12

Pregnant

Detached Retina or Glaucoma

Recent Fractures or Surgery

Diagnosis of aneurysm in the brain or abdomen

Epilepsy/Seizures

Hospitalisation for any psychiatric conditions in the past 12 months

Severe PTSD

None of the Above

Declaration

I declare that the above information is true and current. I understand and accept that Kinesiology is a complimentary therapy and is no way a diagnostic or curative approach. It is also understood that the results of the treatment are not guaranteed in any way. The information gathered here and all session records, will remain the property of Larisa Jayne as part of client history and will be securely stored and kept in strict confidence. I further understand that payment is to be made at the time of service and can be made either by cash, Visa or Mastercard. I understand and accept the Clinic Policies regarding late attendance, non-attendance and cancellation and understand that non-attendance or cancellations made within 12 hours will incur a 50% charge of the session fee.

I Agree