Name (Required) *

First Name

Last Name

Please indicate whether any of the following medical conditions apply to you:

I have been hospitalised for COVID 19

Diabetes

Epilepsy

Asthma

Any heart condition

High Blood Pressure

Low Blood Pressure

Fungal Infection

Surgery within the last 12 months

Varicose Veins

Fractures/Sprains

Given birth within the last six weeks

Breastfeeding

By signing this form you agree that the above sections have been completed to the best of your knowledge. You consent to receive requested treatment(s) and you understand the risks which include but are not limited to; allergic reaction, complications arising from any undiagnosed medical/undisclosed medical conditions or unsuitability for treatment. You also consent to follow the aftercare to the best of your ability. If you would like any advice regarding this please speak to Donna before signing. *

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