Consultation Form

Consent & Data Privacy*

Thank you for booking your Nestled in Nurture appointment. To help me to best support you and for you to gain greatest benefits from your forthcoming treatment/s, please complete all sections on this confidential consultation form. Prior to receiving a Nestled in Nurture treatment, I require your contact details and your medical information. Your details will remain strictly confidential and will not be passed to any third parties. By submitting this form, you are consenting to being contacted via email with similar relevant information from Nestled in Nurture. Please check the Privacy Policy to see how your data is protected and managed: https://www.nestledinnurture.co.uk/privacy-policy/

I consent to my submitted data being collected and stored.

Name*

First Last

Date of Birth*

Phone Number*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email Address*

How did you hear about me?*

Occupation*

Do you have any medical conditions or allergies?*

Yes
No

If yes, please provide details including any regular medication.

Have you had any surgery within the last 5 years*

Yes
No

If yes, please provide details.

Are you or could you be pregnant?*

Yes
No

Any further details.

What are your current areas of concern?*

What are your aims and goals for this treatment and going forward?*

Any other comments?

Client Declaration*

I understand that any treatment carried out by Nestled in Nurture is not considered to be a medical aid and therefore I must ensure that I am also receiving appropriate care from a primary care provider if relevant. I realise the work is being given for my wellbeing. I have stated all medical conditions that I am aware of and will update the practitioner of any changes in my health status. I give consent for my data to be stored on the understanding that they will be in a secure place and kept confidentially. I can ask for them to be deleted at any time.

Confirm

Signature*

Date*

Consultation Form

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