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SOUNDS

Consultation and Consent Form

Please fill out this form ahead of coming in for your treatment. You will only need to fill this once, unless your circumstances have changed.

Full Name

Date of Birth

Email Address

Are you suffering from a medical condition, illness, or injury?

No

Yes

Are you currently taking any medication?

No

Yes

Address:

Name and address of your GP:

Your reason for coming for healing:

Please ensure that you read the Contraindications & Data Policy before signing below.

I declare that I have read the contraindications and data policy agreement, and that the information I’ve provided is accurate & complete. I consent to receiving the requested treatment.

Signed

Thanks for submitting!

©2023 by Safiatú Lopes.

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