Useful Information

Consultation Form

As part of your treatment consultation, we ask that you complete a Consultation Form prior to your appointment. This enables us to make sure your treatment is everything you want, or need it to be.

To save you time on the day, you may complete the Consultation Form below in advance of your visit (although it is not essential you do this).

Complete the form below and send this through to us, or download the PDF, print and complete it. But don't forget to bring it with you to give to your therapist as part of your treatment consultation!

Consultation request form Download the PDF Consultation Form

PERSONAL DETAILS

*Full Name *Date of Birth (dd-mm-yyyy)

*Telephone *Email Address

*Address *Town *County *Postcode

HEALTH DETAILS * CONDITIONS

Please un-tick box if you do not wish to receive further communication (including news and special offers) via email regarding Warner Breaks or other products and services brought to you by Warner.

From time to time you may be sent information on products and services brought to you by Warner Breaks, or carefully selected trading partners. If you prefer not to receive such information, please un-tick this box.

Are you currently under a doctor’s care receiving continual treatment?
Have you had surgery in the last 3 months?
Have you had any heart or circulatory problems?
Are you receiving treatment for cancer?
Have you ever suffered from deep vein thrombosis?
If you have ticked yes to any of the above, you will need to consult your GP before your treatment can be given and produce written permission.