Consultation Form For Clients Consultation Form Name * Name First First Last Last Address * Phone * Email * Date of Birth * Occupation * Doctors Name:- * Doctors address * Do you suffer with any of the following allergies? * Nuts Latex Lactose intolerant Gluten Other allergies None of the above Are you taking any medication? * Yes NO What medication do you take? * Do you suffer with any of the following? * Heart Problems High or low blood pressure Anxiety Diabetes Eczema Dermatitis Epilepsy Cancer Recent injuries Scar tissue Psoriasis Any operations Pregnancy Hormonal problems Thyroid problems Arthritis Inflammation None If 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. * Yes Client signature * Date signed * If you are human, leave this field blank. Submit Δ Spread the love
