Initial information

This form asks about medical history and reasons for treatment. Please answer only if you feel comfortable to do so without having met me in person.

You can reach Touching Well by mobile: 0794 227 6538, or via our landline 0115 648 9636, or the contact form.

Opening times: Monday to Thursday daytime

I hope to see you soon. With warm regards, Regina

Please cancel if you have Covid-19 symptoms, or if you have a positive Covid test.

Please note that all fields followed by an asterisk must be filled in.

Your reason for treatment: *

Please tick if any of the following issues apply to you:*

	heart condition
	high blood pressure
	low blood pressure
	diabetes
	epilepsy
	lung condition
	on steroids
	on anticoagulation (blood thinners)
	osteo/rheumatoid arthritis
	hypermobile
	previous fractures
	previous surgery
	chronic fatigue
	long Covid
	fibromyalgia or post-viral syndrome
	sleep issues
	none of the above

Please espand:

Are you on any medication?

I have *

	not been vaccinated againd Covid-19
	had my first dose
	had both doses of the Covid-19 vaccine
	had one or more boosters

Is there anything else we should know?

How did you find out about Touching Well?

Full name*

Postal address including postcode*

E-mail address*

Contact telephone number*

Occupation

Date of birth*

	consent to having treatment
	understand that the treatment is no subsitute to medical advice
	am aware of the risks
	will let the practitioner know immediately if I feel uncomfortable at any time during the session
	understand that if I cancel a session less than 48 hours prior to the start of the session I am liable for the full fee, unless negotiated otherwise.