New Client Medical Consent

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New Client Medical Consent

Full name

Address

Home tel. #

Mobile

Medical History

Prescribed Medication YesNo

Skin diseases or infections. YesNo

Surgery (past 6 months) YesNo

Pregnancy. YesNo

Heart Conditions YesNo

Respiratory Conditions. YesNo

Immune Deficiency. YesNo

Diabetes/Epilepsy. YesNo

High/Low Blood Pressure. YesNo

Cardiovascular Disease. YesNo

HIV Positive YesNo

Cancer or undergoing Treatment. YesNo

Allergy to any treatment or products YesNo

Other Ailments. YesNo

Covid-19

Are you currently suspected of Covid symptoms? YesNo

Have you been in contact with someone suspected or confirmed of having Covid-19. YesNo

Recent Cough or any respiratory signs within the last 14 days YesNo

Fever/High Temperature within the last 14 days YesNo

Are you over 70 years? YesNo

This data may be held electronically by Cranwell House with your permission YesNo
I give Cranwell House permission to contact me by telephone or email YesNo

I certify that the information I have given is correct

Date

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CLINIC REOPENING

Following the recent government announcement, we are planning to reopen our doors on Tuesday 13th April 2021. Please email [email protected] to be added to our booking list, with your treatment request/s and contact telephone number. We will respond to all enquiries as soon as we can.

Covid-19 Measures and Procedures.