Consultation Card

Consultation Card
Name

First NameLast Name
Address
Contact number
Email address
example@example.com
Would you like to sign up to Zenphoria's newsletter?

YesNo
(Zenphoria will use your email address to send newsletters and promotions and use your phone numbers for appointments and contact you in the future)
Where did you hear about Zenphoria
D.O.B:
Emergency contact name:
Emergency contact Number:
GP name
GP address
Please fill in any Medical History (medication, allergies, injuries, etc.)
Are you on any medication?

YesNo
if yes please detail name? what its for:
Please tick if you have any of the below:

Allergies including hay fever:Skin conditions including Dermatitis or Eczema or Psoriasis or Acne:Asthma or breathing difficulties:Diabetes:Pregnant:Undiagnosed pain:Arthritis:Warts or Verruca's:Eye conditions:Cold Sores:Other:
If you said yes to any of the above please give details below or if there is anything else that might affect your treatment:
I, the undersigned agree that the information above is to the best of my knowledge accurate and true and I have declared any conditions that I suffer from, I have been informed about the contraindications and possible reactions to the treatment and am willing to proceed, I hereby give my consent to the treatment I am about to receive.
Zenphoria never shares or sells data to any third party and all data is used according to Zenphoria’s privacy policy found on the website. Please select how you would like to be contacted in the future for appointments, promotions, newsletters, etc

Email address:Phone number:Address:None:
Date

DayMonthYear
Date
Newsletter

Yes, subscribe me to this newsletter.
Client Signiture:

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Should be Empty: