Client Consultation Form - Download as DOC by 79i0F5

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									                                 Urban Kneads Mother And Baby
                                    Client Consultation Form
                                         PARENT’S DETAILS
Title                                 First Name                          Surname
Date of Birth
Address                               Home No                             Mobile
                                      Email
                                      Occupation
Postcode                              No of                               Ages
                                      Children
GP Name                               GP Address
GP Tel No
How Did You Hear About Urban Kneads?
                                          BABY’S DETAILS
Full Name
Date of Birth
Health Visitor
Has Baby Attended Their Paediatric Check (around 6 – 8 weeks?)                Yes               No
                                  BIRTH DETAILS & BABY’S HEALTH
Weight At Time Of Enrolment
Type of Birth
Does Baby Suffer From Any Medical Conditions Or
Allergies?
Does Baby Have Any Know Hip Problems?
                                            VACCINATIONS
                                                   Date                             Reactions
2 months
3 months
4 months
                  POSSIBLE CONTRAINDICATIONS AT TIME OF ENROLLMENT
Vomiting                                                                        Yes              No
Skin Rash                                                                       Yes              No
Infections                                                                      Yes              No
Cut / Wounds                                                                    Yes              No
Diarrhoea / Constipation                                                        Yes              No
Temperature / Fever                                                             Yes              No
Bruising / Swelling                                                             Yes              No
Scars / Inflammation                                                            Yes              No
Any Other                                                                       Yes              No
     I confirm that all the information given is correct and up to date. I understand all information
                recorded concerning me and my baby will be held as strictly confidential.

Signed:                                                        Date:
                                          COURSE DETAILS
                                                                 Preferred Start Date & Time
Baby Massage
Baby Yoga
Dads’ Course
Cancellation Policy

Once your Client Booking Form and payment is received, it is strictly NON-REFUNDABLE.
The only exception to this is if the cancellation is due to a medical condition, which (at Urban
Kneads’ discretion), genuinely prevents you from participation in your chosen class. In these
approved circumstances, a £7.50 administration charge will be deducted from your full refund
to cover the cost of booking time, bank charges and postage.

TRANSFERS: We will consider a transfer to an alternative course or later course (subject to
availability) but require at least 10 WORKING DAYS NOTICE to approve said transfer.
Transfers arranged later than 10 days prior to commencement of booked course may be
subject to a 25% cancellation charge, to take into account the fact that we may not have
time to find a replacement for your original booked place.

								
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