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Personal Details & Medical History

Please complete the below preliminary medical questionnaire after which we will be in contact to book a time for a face to face consultation.


I understand treatment is dependent on assessment of suitability at the appointment and at the discretion of the practitioner.

Relating to your mental health please tick if you suffer from any of the following:
Relating to your personal health please tick if any of the following apply to you:
Relating to COVID-19 please tick if any of the folloing apply to you:

Thanks for submitting!

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