Harrogate Holistics Consultation Form
Please fill this form out before you arrive at your appointment to save time and ensure you get your full treatment time. Treatments cannot be carried out without this form.
Email address *
Name
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Contact Number
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Address
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Are you currently under the care of a Doctor?
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Do you have a particular area of concern?
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Are you, or could you be, pregnant?
Please let me know of any health issues or requirements you would like me to know about (include health restrictions or other health concerns.)
Your answer
Do you have High or Low Blood Pressure?
How would you describe your skin?
Do you have any allergies?
Your answer
Do you, or have you, ever had a Cancer diagnosis? (If Yes, please state when you were diagnosed, the type of Cancer and any treatment you are having or have received)
Your answer
Are you looking for (please tick all that apply)
Do you have any additional comments, concerns or questions before our treatment? All completely confidential, please feel free to raise these with me before your session.
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Please date your consultation form
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