Strictly private and confidential

In order for me to carry out the safest and most beneficial treatment for you, it is necessary to ask the following questions. Please read carefully and select ALL answers that apply.

Disclaimer for my records, I need to confirm that you have read, understood and answered all of the questions below. If there is anything you do not understand , please ask me. Otherwise please read the following below.

To the best of my knowledge, the information I have given is true and I have not withheld any information concerning my health. I will keep the you updated on my health should there be any changes to answers given. I understand there is a possibility I may experience some minor reactions as my body adjusts to the treatment.

I understand that the therapist does not diagnose illness, disease or any other physical or mental condition. I understand that this treatment is not a substitute for medical examination, diagnosis or treatment. While I recognise that all due care will be taken by the therapist, I am aware that my participation in the treatment is voluntary.

By submitting this Form you give consent for me to keep the medical information on file, as per the new data protection legislation May 2018.