Health Declaration

Please fill out the following form
before your treatment

First name

Last name

Email

Date of Birth

Select an Address

Please Tick below if you've had/ have any existing conditions

Allergies

Anit- depressants

Blood Pressure

Cancer

Contact Dermatitis

Diabetes

Epilepsy

Hepatitis

Hiv Positive

Infection

Inflammation

Metal Implants

Ms

Numbness

Pacemaker

Heart Condition

Pregnant

Recent Operation

Scar Tissue

Thrombosis

Varicose Veins

If any of the above is ticked please write details below.

I declare that the info I’ve provided is accurate & complete

Emergency Contact Details:

Initials

Thanks for submitting!

Unit 2 Block C, Prow Park, Treloggan Business Park Newquay TR7 2SX

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