Membership Application

Please complete this form and press submit. We will confirm your membership by email. You will be required to to sign the form on your first visit.

Your name

Your email

Telephone No

Membership Status
---PatientCarerOther

Your address

Date of Birth

GP name and address

Medical diagnosis

Medical restrictions

Plerase add any information we may need to know

I consent for my data to be sent via this form and shared amongst HCS therapists

Please tick

Consent: I confirm I will accept treatment only after the therapy and potential aftercare has been described to me. This is to ensure any consent I provide may be considered to be informed consent.
I understand the record of my medical condition / treatment received will be treated as strictly confidential and kept in secure facilities and will only be circulated within the group on a need to know basis. I understand there is no guarantee regarding the effects of any treatment offered by the HCS. I confirm I take full responsibility for any treatement received.

Please tick

This form will treated in confidence once submitted