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Health Questionnaire
Please fill out the following health declaration form in order to participate in your treatment.
First Name
Last Name
Address
Phone
Email
Date of Birth
Occupation
Doctors Name
Doctors Address
Any Known Medical Conditions
Any Known Allergies
Treatment(s)
Date of Treatment(s)
Are you experiencing any Covid 19 symptoms?
No
Yes
Have you had the Covid 19 Vaccine?
No
Yes, 1st Dose
Yes, Fully Vaccinated
I confirm that the information given in this form is true
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Therapists Signature
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