Legal name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent to treatment *

I have read and understood your policies and procedures and consent to treatment.

I have read and understood your GDPR policy.

Consent to contact *

I am happy to be contacted via email

I am happy to be contacted via telephone

Cancellation & rescheduling policy *

We operate a standard 48 hour cancellation/rescheduling policy. If you need to cancel or reschedule please do provide us with a minimum of 48 hours notice. Payment will be required for sessions that are cancelled, rescheduled or missed with less than 48 hours notice

I have read, understood and agree to your cancellation and rescheduling policy.

Payment policy *

I understand and agree that I am responsible for paying for all services provided.

If I am paying with insurance, I understand that I'm responsible for making payment in the event that my insurance provider declines payment for any reason.