Your Groupon Security Code OR Wowcher/living social code (required)

Your Name (required)

Preferred Appointment Time (list up to 3 convenient times) (required)

Preferred Appointment Day (list up to 3 convenient Days) (required)

Your Phone(required)

Your Date of Birth(required)

Your GP's Name and their address(required)

Your Emergency Contact Name & Number (required)

Your Occupation

Your Main Problem that brought you to us (required)

Type of Pain
StabbingBurningPins & NeedlesNumbnessAching

Your medical History (please check any that relates to you, past or present)
AllergiesArthritisAsthmaAnkle SwellingAnginaBladder infectionsCancerChest painCold sweatsChronic ThrushConstipationCystitisDiabetesDiarrhoeaDifficulty breathingDifficulty urinatingDizzinessEczema/skin problemsEpilepsy/fitsEye ProblemsFatigue/TirednessGrinding teethHeadachesHeart attack(s)Hearing problemsHigh blood pressureIndigestionJaw pain/ClickingJoint swellingLoss of balanceLoss of consciousnessLoss of taste/smellLoss of visionLow blood pressureNumbnessOrthodontic workPalpitationsProstate problemsPins & NeedlesRapid weight lossStroke/T.I.A.Sinus problemsTeeth removedVaricose veins

Female specific Questions
Are you pregnant?Have you given Birth?Did you experience complicationsHave you had a caesarian section?Do you have irregular periods?Do you have painful periods?Do you suffer from PMTHave you had a hysterectomy?Are you on HRT?

Data Protection Information

Informed consent
I consent to Treatment (when I have fully discussed the problem with my practitioner)Information Sharing Consent (ie your GP or your Insurance Company with your prior permission)Marketing Communications (such as Birthday Cards, Christmas Cards, Special Offers, Newsletters from this clinic only)Recording Personal Data

Consent To Treatment
I confirm that I have answered the above questions relating to my health and conditions I am suffering from honestly and that I will be fully informed about Remedial Massage Treatment and how it can help me.I also confirm that I will be given the opportunity to ask questions and that these have been answered to my satisfaction.I agree to the Treatment and I confirm that I have been advised of possible side effects which include but are not limited to dizziness, light headedness, soreness and/or aching, sensitivity and possible bruising.I confirm I have been made aware of and understand the clinic data policy.** Children under 16 may consent but they must have the signature of a parent or guardian