Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Please tick the relevant box if you have any of the following conditions

Headache

Migraine

Insomnia

Diabetes

Epilepsy

Allergies

Pregnant/IUD

Diections/Bowel problems

Heartburn/reflux

Circulation problems

Varicose Veins/Thrombosis

High/Low blood pressure

Arteriosclerosis

Stroke

Respiratory problems

Asthma

Urinary problems

Hormonal problems

Skin problems

Cancer

Declaration *

I declare that all of the aforementioned is true to the best of my knowledge. I confirm that I do not have any infectious diseases and I agree to inform the practitioner should my health condition change or deteriorate. I understand that Amatsu uses touch and mobilisation. I consent to the practitioner holding and moving my body to facilitate the treatment. I agree that David and Alan McCarthy, in accordance with the Data Protection Act 1988 may hold and process the personal data in this form and any further data relating to my treatment. All information will be treated as strictly private and confidential. Should consultation or referral be necessary, the practitioner will obtain the clients permission before disclosing any information.

Yes

I understand that failture to keep and appointment or provide notification of cancellation at least the day before my appointment will result in the full fee being charged. *

Yes

Have you developed any of the following as new symptoms for you in the past 2 weeks? *

Fever

Cough

Sore Throat

Shortness of breath

Difficulty in breathing

Cold or flu-like symptoms

Sudden loss of smell or taste

Diarrhoea

Sudden loss of energy

None of the above

Have you had any contact with a confirmed case of Covid-19 in the past 2 weeks? *

Yes

No

Have you had a positive test for covid-19 in the past 2 weeks? *

Yes

No

Have you travelled outside the country in the past 2 weeks?

Yes

No

Name *

First Name

Last Name