Registration Form - FreemanWorks

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This form gives me relevant information for scheduling and treatment.
If my schedule is full, I can either put you on a wait list or direct you to a practitioner in your area. In all cases I will contact you to discuss the possibilities.

I can assure you that the information in this form will be treated with the utmost confidentiality.
After filling in the form, please click on the "Send" button at the end.
Thanks for your interest.

Fields marked * are required for submission.

 


Basic Information

 

Full Name*:

 

Address Line 1:

 

Address Line 2:

 

Postcode:

 

Town/ City:

 

E-mail*:

 

Telephone*:

 

Date of Birth:

 


Health Questions

 

Do any of the following conditions apply to you?

 

Diabetes
Heart disorders
Hemophilia
Hepatitis
HIV/ Aids
High blood pressure

Pituitary disorder
Cancer
Migraine
Pacemaker
Pregnancy
Epilepsy

 

Do you bruise easily?

yes
no

 

Do you suffer from any other major illness?

yes
no

 

If yes, you can tell me about it below, but this is not required.

 


Availability

 

Which of these times are you available?

 

09:00 - 12:00

12:00 - 15:00

15:00 - 18:00

Monday Tuesday Wednesday Thursday Friday

Monday Tuesday Wednesday Thursday Friday

Monday Tuesday Wednesday Thursday Friday

 

From which date could you start treatment?

 


Comments

 

Please feel free to add anything else you think I should know.