Client Consent & Medical History Form

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General Data Protection Regulations 2018.

The information on this form may be held on computerised records. Strict confidentiality will be observed and disclosures will only be made for medical and personnel administration purposes.
Your Full Name Your Full Name First Last
Your Date of Birth Your Date of Birth / DD / MM YYYY

Why do we need to know this? You need to be aged 18 years and over to receive treatment.
Your Contact Number
Your Email Address
Your Address Your Address
Street Address Address Line 2 City Postal Code
Your GP Details

Why do we need these details? By law, we have to notify your GP of your treatment with us if you become unwell during your session.
Your GP Name Your GP Name First Last
Your GP Contact Number (without spaces)

Please enter your GP's telephone number without any spaces.
Your GP Address Your GP Address
Street Address Address Line 2 City Postal Code
What is your current job status?
What is your current stress level?

What is your current stress level?
1 2 3 4 5 6 7 8 9 10

LOW

HIGH

Why do we need to know this? To ensure we provide a tailored treatment to your individual needs at the time of your session.
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.