Full name*
Date of birth
Address*
Address line 2
City*
Postcode*
Email address*
Home phone
Mobile
Doctor’s name and address
Medical History - Do you suffer from any of the following? Heart conditions/pacemakerSevere circulatory disordersDiabetesSkin disordersKidney problemsSwelling/oedemaMetal plates/pins/piercingsRecent scar tissue/surgeryExcema, PsoriasisCancerArthritis/RheumatismAre you pregnant or breastfeedingStrokeClaustrophobiaHepatitisHeadachesRespiratory problemsBack problemsFungal InfectionsIBS/Bowel problemsAllergiesHigh/low blood pressureOperation in last 6 monthsEpilepsy
Any other medical conditions/ailments Please give more information or if you have marked yes to any of the above…
Are you currently on any medication or under medical supervision? If so please give details including name of medication
Declaration
I declare that the above information I have given concerning my health is correct and I have read and understood the questions asked and I have not withheld any information that may be relevant to my treatments.
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Date
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