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Date and time
Day
Month
Year
Time
HoursMinutes
Are You Pregnant?
Yes
No
Do You Suffer Or Have Suffered From

Client Declaration

I confirm that I have provided accurate information about my medical history and general health. I understand that Detox by Michelle cannot be held responsible for any omissions or errors in this form.


Therapy Consent

I give permission for myself/my child to receive this therapy. I understand that all information shared is confidential. Treatments are intended to support wellbeing and not replace GP or medical care. If my health changes, I will inform my therapist before my next session.


Date of signature
Day
Month
Year
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