Pre-consultation information and consent form

Pre-Consultation Information Form

Please fill out the form carefully
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number

Area CodePhone Number
Briefly outline your reason for enquiry and some background on the issue
Medical History / Medication
What do you want to achieve through working together?
Data Protection and Privacy

Please note we will store your data responsibly and safely in accordance with UK data protection guidelines. (visit www.ico.org.uk)

We will not disclose any information given by you without your consent. Any contact information will only be used regarding appointments and other professional activities.
Please tick below:
Consent and Payment of Fees

During your initial consultation, you will have a detailed case history taken by your practitioner. This will involve questions to diagnose an issue or how to best cater for your needs. If you feel uncomfortable at any stage during the consultation you must inform your practitioner and they will immediately halt any further questioning.

It is important to know that appointment times are guidelines and may run shorter or longer from case to case.

If you need to cancel or rearrange a scheduled appointment, this should be done within 24 hours of the proposed time to avoid a cancellation fee of 50% appointment charge.

All payments should be made via bank transfer according to the details received on the invoice.

Having read and agreed to the above information, please sign below:
Signature
Should be Empty:

Pre-Consultation Information Form