Health & Registration Form

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Please complete and submit this form before attending a Soundbath with Andy and Stacey. All information provided will be kept in the strictest confidence. You do not have to disclose anything that you do not wish to, but the information you give will help Andy to meet your needs in the Soundbath. If you have any concerns about a medical condition which may affect your ability to attend a soundbath then it is advisable to consult a healthcare professional before attending.

Email *

First Name (Name you wish to be known by) *

Last Name *

Mobile phone number (in case of urgent contact to advise of changes to sessions) *

Have you attended a soundbath before? *

Yes

Please indicate if any of the following health conditions currently apply to you *

Pregnancy (note a soundbath is NOT suitable during the 1st trimester)

Epilepsy or seizures (particularly if triggered by sound)

Metal implants have been fitted (i.e. replacement hip or pacemaker)

Anxiety/Stress

Depression

Chronic pain or fatigue

Other

Nothing to report

Required

If you have answered yes to any of the health conditions above, please provide any further information you would like to share, especially that which you consider relevant to your soundbath experience. If you are pregnant, please indicate approximately how many weeks:

What brings you to a soundbath?

How did you hear about Painting Sounds?

Web Search Engine

Facebook

Word of mouth

Noticeboard poster

Leaflet through door

Other:

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Painting Sounds would like to add your details to their mailing list in order to email updates and information about yoga classes and events.
*

I opt in to email updates

please do not add me to the email mailing list

I understand and agree that any information, instruction or advice obtained from Andy or Stacey at Painting Sounds should NOT be used as a substitute for advice or treatment given by a doctor or other healthcare professional. I take full responsibility for my own health and wellbeing during the session and agree that I participate in a soundbath at my own risk.
*

I agree

Required

The details given above are true to the best of my knowledge as at todays date:
*

YYYY

A copy of your responses will be emailed to the address you provided.

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