Consultation Form

Name

Date of Birth

Address

Telephone Number

Email Address

Occupation

G.P. Name, Address & Telephone Number

Any Known Allergies?

Are you pregnant? Are you pregnant? Yes No

Have you had any of these health problems PAST or PRESENT? Have you had any of these health problems PAST or PRESENT? High Blood Pressure Low blood pressure Diarrhea & Vomiting Heart Conditions Stroke Depression/Anxiety Disorders Diabetes Skin Disorders Athletes foot Cancer, please give details below Epilepsy Blood Disorders Asthma Thrombosis/DVT Fatigue Frequent headaches/migraines Perimenopause/Menopause

Please give further details of any health condition you may have, & how it affects your daily life.

Have you underwent any surgery or medical procedure in the last 6 months?

Please list any medication you are currently taking and why..

Have you tried any other complementary therapies in the past?

Client Decleration Client Decleration I declare that the information I have given is correct to the best of my knowledge and I have not withheld any information relevant to the treatment. I have been fully informed about the nature of the treatment I am receiving and the after effects, I may experience. I am willing to proceed with the treatments. I can confirm that I am feeling well and have no flu, cold, covid or other respiratory symptoms in the week leading up to my treatment or at the time of my treatment. If I do feel unwell or have a high temperature I will be in touch as soon as possible.

Client Cancellation Client Cancellation If I am not able to make a scheduled appointment, I agree to cancel the appointment 24hours in advance. If I miss an appointment without giving 24hr notice, I agree to pay the missed appointment charge. I have read and agreed the Terms & Conditions