Consultation Form
Date
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Name
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First Name
Last Name
Date Of Birth
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Occupation
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?
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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
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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
Other Please Fill In Below
Any additional health or medical information
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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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