Consultation Form
Consultation Questionnaire Form.

For Sound Acupuncture, Colour & Reiki Sessions.

All information will be treated and used in confidence.

Full Name *
Your full name.
Your answer
Address *
Your address
Your answer
Phone Number *
Your phone number
Your answer
eMail Address *
Your email address
Your answer
Marital Status *
Your marital status
Date Of Birth *
Your date of birth
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/
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Details of any medication you are taking:
Your answer
Please describe any significant events in your medical history: (with dates)
Your answer
Describe any symptoms/problems that you want to address:
Your answer
Have you used any other complementary therapy? If yes, give details.
Your answer
Are you allergic to essential oils? If so please state which.
Your answer
How did you hear of Tim Elliston Holistics? *
DECLARATION - You appreciate that you will not be given a medical diagnosis or treatment as part of my complimentary therapy sessions. You understand that your GP is responsible for your care or that of your dependent. You understand that any positive effects from your treatment may take a few days to realise and more thst one treatment maybe required. *
Declaration.
Required
DECLARATION - Please enter your full name followed by todays date. *
by way of a signature please enter your full name and the date.
Your answer
In the case of the person being treated is under 16 years old a parent or guardian should sign above. Please state relationship. *
Parent or guardian
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