Apply for Reflexology/Massage

Your name:

Address:

Email:

Phone:

Applicant Status: (Please Choose)

You will be required to supply evidence of your diagnosis (e.g. copy of email/letter or text) Please tick this box to confirm you have evidence.

Preferred Appointment Date (Every Second Tuesday of the month from 8th July 2025):

What type of therapy would you like to apply for?

Reflexology

Massage

Reiki

Any other information you'd like us to know about:

Date: