Consultation Form For ClientsConsultation FormName *Name First FirstLast LastAddress *Phone *Email *Date of Birth *Occupation *Doctors Name:- *Doctors address *Do you suffer with any of the following allergies? *NutsLatexLactose intolerantGlutenOther allergiesNone of the aboveAre you taking any medication? *YesNOWhat medication do you take? *Do you suffer with any of the following? *Heart ProblemsHigh or low blood pressureAnxietyDiabetesEczemaDermatitisEpilepsyCancerRecent injuriesScar tissuePsoriasisAny operationsPregnancyHormonal problemsThyroid problemsArthritisInflammationNoneIf you answered any other medical condition,what is the condition? *Date of treatment *Treatment booked for? *As the client I believe the information above to be true. *YesClient signature *Date signed *SubmitIf you are human,leave this field blank. Δ