PRE Treatment questionnaire

and client agreement

Please kindly complete the below questionnaire and agreement 24 hours before your appointment.

Client takes full responsibility for their baby’s health and well being, and accepts the outcomes of any advice or treatment they receive; Client accepts them as being complementary to and not an alternative to professional medical treatments. Client will consult their GP regarding supplements if they are taking medication.

Nutritional supplements where recommended are charged separately.

Cancellation Policy

Missed appointments without 24 hours notice will be charged at the full rate.

Parent Name

First Name

Last Name

Infant's Name

First Name

Last Name

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth of infant

YYYY

Is your infant currently being breastfed?

Yes

Have you had any medical conditions that started during or after pregnancy? Please outline

Please give an outline of any physical health symptoms or issues your infant is currently experiencing

Please list any medication you (if breastfeeding) or your infant is currently taking

Please list any supplements you (if breastfeeding) or your infant are currently taking

How is your diet (if breastfeeding) and/or your infant's (if on solids) looking at the moment? What does a typical breakfast/lunch/dinner look like?

What is sleep looking like for you currently?

Anything else you would like to add?

I accept responsibility for my infant's health & wellbeing & for participation in the methods, treatment & suggestions made during our sessions:

Yes

I understand that fees are due in advance of each session and that nutritional supplements are charged separately:

Yes

I give explicit consent for my data to be held in accordance with GDPR regulations:

Yes

I agree to the terms set out in the agreement

Yes

PRE Treatment questionnaire

and client agreement

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