Consultation forms medical history

If you have any questions about the above please discuss these with your practitioner. If the answer is yes to any of the above, your practitioner may ask for further details. Treatment may be refused if it is not considered in your own interest to proceed. I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. I confirm that all information provided above is true and accurate. It is your responsibility and not that of the therapist to consult your GP or consultant. By entering information on this form you are hereby indemnifying the therapist against any adverse reaction sustained as a result of the treatment.
Print name and give details of emergency contact and telephone number