consultation advice form

Pleas fill in the form using a pen – preferably black.	Alternatively write down if there is anything specific you would like me to dowse: ............................................................................. ............................................................................. ............................................................................. ............................................................................. ..............................................................................
Forename/s: ....................................................
Surname : ......................................................
Date of Birth: .................................................
Address: ......................................................... ....................................................................... .......................................................................
Postcode: ......................................	Please list any supplements / medication you are currently taking : .............................................................................. ............................................................................. ............................................................................. ..............................................................................
Occupation: .......................................................
Phone : ..............................................................
E-mail: .............................................................
How did you hear about the School of holistic dowsing? ………………………………………………	Pregnant: Yes No Please list any health condition or serious illness: ................................................................................. ................................................................................. ................................................................................. ................................................................................. .................................................................................
*Disclaimer All advice provided does not replace qualified medical advice. If you have or suspect you may have a health problem, you should consult your health care provider. Each person assumes sole responsibility for any decisions made based upon the advice given.
Date: ……………………………………. Signature: …………………………………….……

Pleas fill in the form using a pen – preferably black.

Alternatively write down if there is anything
specific you would like me to dowse:

.............................................................................

..............................................................................

Forename/s: ....................................................

Surname : ......................................................

Date of Birth: .................................................

Address: .........................................................

.......................................................................

Postcode: ......................................

Please list any supplements / medication
you are currently taking :

..............................................................................

.............................................................................

..............................................................................

Occupation: .......................................................

Phone : ..............................................................

E-mail: .............................................................

How did you hear about the School of holistic dowsing?
………………………………………………

Pregnant: Yes No
Please list any health condition or serious illness:

.................................................................................

*Disclaimer
All advice provided does not replace qualified medical advice. If you have or suspect you may have a health problem, you should consult your health care provider. Each person assumes sole responsibility for any decisions made based upon the advice given.

Date: …………………………………….

Signature: …………………………………….……