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01639 635000

Client Consultation

First Name

Last Name

Email

Date of Birth

Phone number

Emergency Contact

Do you suffer with any of the following

Allergies

High/low blood pressure

Eczema

Arthritis/Rheumatism

Asthma/lung problems

Diabetes

Thyroid problems

Heart conditions

Cancer

Epilepsy

Back problems

Muscular

Headaches

Varicose Veins

IBS/Bowel Problems

Claustrophobia

Fungal infection

Pain

Thrombosis

Metal pins/plates

Pacemaker

Other

Have you had any surgery or operations in the last 6 months? *

Yes

No

If yes, please give details

Are you pregnant/breastfeeding? *

Yes

No

If yes, please give details

Are you currently on any medication or under any medical supervision? *

Yes

No

If yes, please give details

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If you answered yes to any health conditions, please give further details here...

I have read and understood the questions asked and confirm that the answers I have given are correct and that I have not witheld any information that may be relevant to my treatments

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