New Reservation Registration

/New Reservation Registration
New Reservation Registration2018-04-13T19:35:15+00:00

氏名 / Your Name (required)

Eメール / Your Email (required)

住所 / Address (required)

ポストコード / Postcode (required)

生年月日 / Date of Birth (required)

電話番号 / Phone No (required)

携帯電話 / Mobile No (required)

お仕事の電話 / Work Telephone

How did you hear about the practice?

Pharmaceutical Medications (Please list those you are currently taking)

What is/are your main complaint(s)?

Medical history (Surgeries/Hospitalisation/Injuries)

INFORMED CONSENT FOR TREATMENT: Please read and agree to our terms conditions
治療への同意: 必ずお読みの上同意願います

I hereby request and consent to the performance of acupuncture treatment, massage treatment, manual therapy and other related procedures, including physical examinations, the use of acupuncture needles and modalities of heat (moxibustion), massage on myself (or the patient named below, for whom I am legally responsible).
Though treatments and therapies are usually beneficial and seldom cause any problems at all, I understand and am informed that as with any medical treatments there are risks involved.