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01977361405

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Home
About Us
our services
Who is Andrea
How we work
Event/Calendar
Group support
Book Now

Menu

Home
About Us
our services
Who is Andrea
How we work
Event/Calendar
Group support
Book Now

Client Information Form

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

ADDRESS(Required)

POSTCODE(Required)

MOBILE NUMBER(Required)

E-MAIL ADDRESS(Required)

SURGERY NAME(Required)

ADDRESS(Required)

NEXT OF KIN CONTACT NAME AND TELEPHONE NUMBER IN THE EVENT OF EMERGENCIES(Required)

ARE YOU PREGNANT?(Required)

Yes

No

DO YOU HAVE ANY ALLERGIES?(Required)

Yes

No

IF YOU HAVE ALLERGIES PLEASE STATE AS OILS ARE USED(Required)

ARE YOU CURRENTLY RECEIVING ANY MEDICAL TREATMENT?

Do you have a pacemaker?(Required)

Do you have a DNR?(Required)

Are you on Blood Thinners?(Required)

ARE YOU TAKING ANY CURRENT MEDICATIONS?(Required)

Yes

No

IF YES PLEASE STATE(Required)

PLEASE SIGN AND DATE TO AGREE THE ABOVE INFORMATION IS CORRECT:

PATIENT SIGNATURE(Required)

Date(Required)

DD slash MM slash YYYY

Consent(Required)

By returning this form you confirm you have read the GDPR document on our website and agree

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New Client Form
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Disclaimer
Terms & Conditions
Privacy Policy
New Client Form
Make A Review

Contact Info

01977361405

07935210477

reception@andreas-healingcentre.co.uk

61 Bridge Street Castleford, WF10 1HH

G-76MRZY8740

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