Patient form

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


    Your Name*

    Date of Birth

    Gender

    Appointment date

    Appointment time

    Occupation

    Your Email*

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

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

    Address

    Postcode

    Country*

    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?

    YesNo

    (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

    YesNo

    Blood Pressure

    HighLow

    Epilepsy

    YesNo

    Heart Attack

    YesNo

    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?

    DISCLAIMER

    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

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