Consultation Form

Name *

What Gender are you? *
MaleFemale

Email Address *

Date of Birth *

Street Address *

City *

Postcode *

Phone *

Occupation *

Hobbies/sports/activities *

Presenting condition (reason for seeking treatment) *

Describe any operations, illnesses, accidents or injuries you may have had (include year and treatment received) *

Are you currently under any medical care? *
YesNo

Please tick the treatment/s you wish to book for: *

If you don't know what treatment you would like please tick the 'Other' box and we can have an initial consultation

Bowen TechniqueIEMTCuppingIASTMTMJ TherapyMSTR TherapyMassage TherapyFacelift MassageOther

Consent *
I confirm details on this consultation form are an accurate record of my medical history and current conditions. I hereby confirm that I have understood the treatment that I am to receive and confirm I am willing to proceed without confirmation from my own GP or Consultant. I have read the Deposit & Cancellation Policy.

Date *