Your name
Date of Birth
Address
Mobile
Occupation
Gender ---MaleFemaleOther
Doctors Details
Doctors Name
Surgery
Client Declaration I am aware that this treatment is for health and wellbeing and is not a substitute for medical advice or professional care. I have read the information leaflet provided and understand that it should not be used for diagnosing or treating a health problem or disease. If I suspect that I have a health problem, I will consult my GP. I understand that pregnant or lactating women will not be allowed this treatment and should seek medical advice if they have concerns about their health. I agree that to the best of my knowledge the details contained in this document are correct.
Sign Name
Date Signed
GDPR: General Data Protection Regulation Policy. May 2018. This is to advise that you grant permission for me to retain, in locked files, details of your address, age, medical details and details of treatment for a period of eight years. The information is necessary to enable me to formulate adequate treatment for you and will not be passed on to any third party.At the end of the eight -year period the record will be destroyed.
I understand and grant permission for the above actions.