client registration

Information is held in accordance with GDPR and will not be used for marketing purposes or shared with any third party without your prior consent. It is helpful to have some details should you become unwell in any of our sessions, particularly an emergency contact. You may or may not wish to share details about your GP - either is fine and we can chat further about this if you would like.

Name

First Name

Last Name

Date of birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact (name & number)

GP details (optional)

Medical conditions, regular medications or anything else you would like me to know about

Client Information

I agree with the information contained in the client information sheet provided to me.

Yes