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CLIENT INTAKE FORM

Health declaration

Please fill out the following form.

First name

Last name

Email*

Date of birth

Day

Month

Year

Have you been hospitalized in the last 12 months?

No

Yes

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

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

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Pure Rejuvenation provides complementary therapies for wellbeing purposes only and does not provide medical diagnosis or treatment. Always consult your GP or qualified healthcare professional regarding any medical condition.

PURE REJUVENATION

Marine House,

Steeple Rd,

Mayland

CM3 6AX

Tel: 07521 973 903

Email: info@purerejuvenation.co.uk

TREATMENT HOURS

CLINIC

Monday: 10 am - 6 pm (Alternate)

Tuesday: 9 am - 5.30 pm

Wednesday: 10 am - 8 pm

Thursday: 10 am - 8 pm (Alternate)

MOBILE CLINIC

Friday: 10 am - 5.30 pm

Saturday: Closed

Sunday: Closed

Out of hours bookings upon request

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