Contact

Client name

D.O.B

Address

Phone

Occupation

Have you recently visited a Doctor/Consultant/Chiro in regards to this issue

Medication

Main reason for attending back2normalclinic

Any current problem or known history of the following:

Major illnesses, recent illnesses, major operations, digestive, urinary, neurological problems

do you have any other specific aches and pains, head, neck, hips, legs, feet, arms, hands?

Have you had any sporting injuries, accidents in the past?

General wellbeing, depression, stress, sleep problems, energy levels

Personal details will be kept for 7 years. Personal details are strictly kept between client and therapist. Unless a court issues arises. You have the right to a copy of this contract. I give permission for back2normalclinic to contact me with offers, reminders, treatment advice and any other form of contact required.

24 hour cancellation policy is in place, should I fail to attend payment for appointment will be required on booking.