Consent Form - Dr. Zoë Douglas-Judson, Mindologists Limited

Mindologists & Dr Zoë Douglas-Judson - Consent Form

Please fill in the form below.
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
E-mail*
Please ensure you have confirmed each new session location during the booking process (e.g. Halifax, London, Tunbridge Wells, North East Lincs and On-line).

Please state any current or history of serious medical conditions (including allergies) and emergency procedures received (if applicable):
Please state any prescribed medication, including herbal or natural remedies you are currently taking, or have taken in the last 12 months:
Please state any non-prescribed drugs, narcotics or substances you are currently taking, or have taken in the last 12 months:
Please state any serious illness or health condition(s) that should be declared ahead of the start of your support and guidance:

Mindologists & Dr Zoë Douglas-Judson - Consent Form