Health Declaration

Please fill out the following form
before your treatment

First name

Email

Last name

Phone Number

Date of Birth * required

Select an Address

Please Tick Below If you've had/have any existing conditions

Allergies

Anti-Depressants

High or Low Blood Pressure

Cancer

Contact Dermatitis

Diabetes

Epilepsy

Heart Condition

Hepatitis

HIV Positive

Infection

Inflamation

Metal Implants

Multiple Sclerosis

Numbness

Pacemaker

Pregnant

Recent Operation

Scar Tissue

Sprain

Thrombosis

Varicose Veins

If any of the above is ticked please write details below.

Emergency Contact Details:

I declare that the info I’ve provided is accurate & complete

Your Signature

Thanks for submitting!

Unit 2 Block C, Prow Park, Treloggan Business Park Newquay TR7 2SX

bottom of page