Patient form

Thank you for booking your appointment. Please fill in the below patient form before attending.

Your Name*

Date of Birth


Appointment date

Appointment time


Your Email*

Telephone Number* (please add country code. E.g. +44)

Mobile Number (please add country code. E.g. +44)




What are you hoping to achieve with David Kilmurry?

What are some of your interests, hobbies or leisure activities?

Where is your favourite holiday destination, or somewhere you would like to visit?

What are your symptoms and how do they affect you?

GP/Doctor’s Name

GP/Doctor’s Address

Has your GP/Doctor already been consulted?
 Yes No

(If yes) How long ago?

(If yes) Medical diagnosis provided?

Have you had/do you still have any of the following medical issues?

Anorexia or Bulimia
 Yes No

Blood Pressure
 High Low

 Yes No

Heart Attack
 Yes No

Have you had/do you still have any other medical issues you believe David Kilmurry should be aware of?

If your query is regarding Selective Eating Disorder (SED) or Neophobia, what are your current ‘safe foods’?

Is your SED or Neophobia combined with a fear of being sick, retching or gagging?


Payment for therapy is in advance and is for your time spent with David Kilmurry, Senior Practitioner, Dp HypMBICCH SQ HP. The results will come for free, although are not guaranteed and will require a small degree ofsubconscious co-operation. All appointments are non-refundable.

By submitting this form, I confirm the accuracy of the data provided and I agree to the disclaimer*
 I agree