Consultation Form
Date
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Day
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Month
Year
Date
Name
First Name
Last Name
Date Of Birth
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Day
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Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email
example@example.com
What is the aim of the therapy and What do you hope to achieve? What are your main concerns /ailments?
Are you under the care of a consultant at present? Have you had any illnesses, conditions, operations and injuries?
If you have any of the following health conditions that might affect your treatment or the products used please let us know by circling below
Nut Allergies
Allergies
Cancer/Chemotherapy
Bruise Easily
Diabetes
Contagious Skin Disorder
Heart Condition
High Or Low Blood Pressure
Osteoporosis
Joint Problems
Swollen Joints
Varicose Veins/DVT
Epilepsy/Seizures
Pregnancy
Breast Feeding/IVF
Psoriasis/Eczema
Water Retention/Oedema
Diarrhoea/Vomitting
Fevers
Migraine
Any additional health or medical information
Client Declaration; I declare that the information I have given is true of the best of my knowledge and I understand and agree to the recommended therapy. I declare that I have been informed of possible reactions to the therapy and understand the aftercare advice given. Client Digital Signature
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