Subsequent Treatment Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Treatment

Treatment: *

Please specify: *

Date of last treatment: *

Has there been any change to your medication since your last treatment? *

Please specify: *

Has there been any change to your medical conditions since your last treatment? *

Please specify: *

Has there been any change to your allergies or intolerances since your last treatment? *

Please specify: *

Any additional notes or comments you wish to make regarding your treatment or medical history:

Consent

I hereby confirm that all information provided in this form is true, accurate, and complete to the best of my knowledge and belief.

I understand that it is my responsibility to inform the business promptly of any changes to my contact information, or medical history as this could have an effect on the course of treatment provided.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. If any information has changed since my last treatment I have made a note of it on this form.

Please tick to confirm: *

I have read and understood the statement above.

Client Signature: *

Tap or click on the signature above to sign