Consultation - HEALING-HANDS

Name :

DOB :

Address :

Mobile No :

E Mail Address :

Doctor's Name :

Doctor's Practice Location :

Occupation :

Are you Pregnant? :

Yes

List any Holistic Therapies that you have received before :

List any injuries to date :

List any operations to date :

List any illnesses to date :

List any mainstream or complimentary/vitamin medicine that you are currently taking :

Have you ever been treated for or hospitalized for psychological illness at any stage? :

Yes

Do you have any of the following? :

Give Details :

Name the Following :

Do you suffer from Anaphylactic shock or carry an Epipen? :

Yes

Do you have any allergies to products? :

Yes

Give details :

Have you any special care needs? :

Yes

How much water do you drink per day? :

Give Details :

Do you smoke? :

Yes

Do you drink alcohol ? :

Yes

How many per day? :

How many units per week? :

Please note that any personal information you have provided will be treated in the strictest of confidence and in full compliance with GDPR legislation. Any identifying information you specify will be held by us for the purpose of our business needs, and your data will be held until no longer required.

Desc(Required)

I consent to Healing Hands storing and using my personal data for the sole purpose of learning about my requirements and providing relevant services .

Desc(Required)

I declare that I have given full, correct and true information regarding my state of health and will inform the therapist of any future changes to my health. I give permission for you to hold my records in order to deliver your services.

Signed :

Date

Healing Hands is a holistic wellness salon providing the local community with natural healing therapies to ease physical and emotional discomfort.

Contact Me

[email protected]
089 4420923
88 Lower Yellow Road, Waterford

Business Hours

Monday, Thursday, Friday & Saturday 10am to 7pm Closing.
Tuesday & Wednesday 10am to 9pm Closing.

Terms & Conditions | Privacy Policy

Consultation Form

Newsletter

Contact Me

Business Hours