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Intake Form for the Cocoon
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Please complete this form prior to your appointment so that we may tailor your therapy to suit.
Full Name
*
Birth Date
*
Day
Month
Year
Gender
*
Female
Male
Non-binary
Email
*
Mobile Phone
*
Home Address
*
Home Address
Suburb
Postcode
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
The use of the Cocoon is not recommended with the following conditions. Please tick all that apply:
If any of the following apply to you, please consider an alternate therapy.
Epilepsy
Active cancer
Broken bones / slipped disc
Intoxication
Infectious/contagious skin conditions/lesions
Pacemaker/defibrillator
Pregnancy/lactating
Heart Disease
Diabetes
Implants
Do you have any health condition or problem that you experience on a regular basis?
*
(eg. high blood pressure, lower back pain, arthritis, etc.
Yes
No
Please list:
Are you currently taking blood pressure medication?
*
Yes
No
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