New Client Consultation | Natthida Therapeutic

First name

Last name

Birthday

Day

Month

Year

Email

Address

Phone

Emergency Contact

Occupation

Sports/Hobbies

Any Allergic Reactions:-

Are you undergoing treatment for any condition?

Are you taking any medication at present?

Any operations? If yes please provide brief detail

WOMEN ONLY- Are you pregnant?

Any type of cancer?

If Injury- please give brief details.

DISCLAIMER

I confirm that the above information I given is accurate to the best of my knowledge. I will keep my therapist up to date with any change to my physical health. I know no reason why i shouldn’t receive treatment.I understand that treatment undertaken by me at my own risk and that the therapist may not be able to cure my complaint.

CLIENT’S PRINT NAME

CLIENT’S SIGNATURE

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Date

Day

Month

Year

WRITTEN PERMISSION REQUIRED BY GP/SPECIALIST ( Additional)

Natthida Therapeutics