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Client Consultation Form

Before your treatment, please take a few moments to complete your confidential consultation form.

This helps ensure your treatment is tailored safely and appropriately to your individual well-being needs.

All information provided is stored securely and treated confidentially in accordance with GDPR.

DOB
Day
Month
Year
Are you currently taking medication
Do you have any medical conditions
Are you pregnant
Do you have any allergies
Have you had recent surgery
Have you received or are you currently receiving cancer treatment.
Epilepsy
Heart conditions

Is there anything else you feel would be helpful for Simone to know prior to your treatment?

Please notify Simone prior to treatment if there are any changes to your health, medications, or medical circumstances.

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