Lead Booking Contact Name: (person who made this booking) *
Date of Visit *
Title * Miss Ms Mrs Mr Dr Mx
First Name *
Surname *
Address *
Town *
Postcode *
E-Mail *
Date of Birth
Mobile Phone
Home Phone
We will correspond with you by email ahead of any visit. Please tick this box if you are happy to receive our emails regarding your booking and information about our exciting offers
Please state here if you have any FOOD ALLERGIES/INTOLERANCES
Please select any of the following conditions which apply to you
Asthma/respiratory problem
Back Problems / joint issues
Cancer
Diabetes
Eczema/Psoriasis
Epilepsy
Fainting / Dizziness
Heart Conditions
High Blood Pressure
Low Blood Pressure
Medication
Multiple Sclerosis
Pacemaker
Pregnant (tell us no. of weeks)
Recent Scar Tissue
Recent Surgery within 6months
Skin Allergies
If you have selected any of the above, please provide additional information
Please list any medication you are currently taking
Treatment Disclaimer (please tick)I certify that the above statements are true and correct. If any of the information submitted today changes, I will let a member of staff know at the earliest convenience. *
Terms & Conditions Disclaimer (please tick) Please tick to confirm that you have read and agree to our Terms & Conditions *
