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The Serenity Shed
CONSULTATION FORM
First Name
Last Name
Date of Birth
Email
Gender
Female
Male
Other
Address
Phone
EMERGENCY CONTACT
Occupation
How did you hear about us?
Do you suffer from any of the following?
Blood pressure issues
Heart disorders
Pacemaker
Epilepsy
Thrombosis
Nervous disorders
Scar tissue
Varicous veins
Oedema
Cancer
Diabetes
Osteoporosis
Back problems
Arthritis
Frequent headaches
Other, please state below
If yes to any of the above, please give specific details
Are you currently pregnant?
*
Yes
No
What are you hoping to gain from your treatment?
Submit
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