New Patient Registration Form

PERSONAL DETAILS

* Indicates required field

Name *

First

Last

Sex *

Date of Birth *

Age *

Marital Status *

Occupation *

Height *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Telephone (Home): *

Telephone (Mobile): *

Weight *

GP's Name / Surgery *

How did you hear about us? *

If an existing patient referred you to us, who should we say thank you to? *

Do you have Private Medical Insurance? If YES, which company? *

EMERGENCY CONTACT INFORMATION

Name *

Tel No: *

Relationship: *

GENERAL HEALTH QUESTIONS

How many per day? *

When did you stop? *

How many units per week? *

Ages of children *

Date of last period *

No. of pregnancies *

Please rate your activity level from 0 - 10 *

Please mark any boxes below if there is a CURRENT problem.

If there are no current problems, please leave blank.

Do you take any medication? *

YES NO

IF YES, PLEASE COMPLETE THE BELOW:

Medication Name *

Reason for taking *

Date Started *

Have you had any surgery? *

YES NO

IF YES, PLEASE COMPLETE THE BELOW:

Surgical Procedure *

Date of surgery *

Have you ever been involved in any accidents? *

YES NO

IF YES, PLEASE COMPLETE THE BELOW:

Type of accident *

Date of accident *

Injuries *

Is there anything else you need to let us know? *

If you have ticked any of the boxes to the left, please give further details below: *

DECLARATION

I, the undersigned, confirm that: *

All of the information provided on this form is correct at the time of submitting and that it is my responsibility to update Total Balance Clinic Ltd should any of that information change at any time I have been informed that this form will be securely kept electronically only I have read the Privacy Policy I give my consent to be contacted as outlined in the Privacy Policy I have had the purpose of care explained to me, and consent to discuss my case with a member of the Total Balance Clinic Ltd team.

Signed *

Date *

GDPR DISCLAIMER

All information provided to Total Balance Clinic Ltd and our approved associates will be kept in the strictest confidence and in accordance with the General Data Protection Regulation. Total Balance Clinic Ltd will not share any information with any third party without your consent. For further information, please refer to our Privacy Policy.
Links to our Website Privacy Policy and Clinic Privacy Policy can be found at the bottom of this page.

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