Client Consultation Form

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Medical Details & History

Conditions

Should any of the below conditions be checked, please use the additional box to elaborate.

Medication | Treatments | Additional Information

COVID-19

COVID-19 symptoms include fever, shortness of breath and coughing

Oncology ?

If you are having an Oncology treatment please complete the below

If the answer to the Oncology question is 'yes' please shower before the touch therapy, or return after 24 hours post infusion.

Declaration

When submitting this form I declare that the above information I have given concerning my health is correct

Updates | Changes

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