Consultation Form - Samantha J Goddard

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Samantha J Goddard

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Before our session, I invite you to fill in the form below in order for us to make full use of our time :

First Name

Last Name

Date of Birth

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Phone

Occupation

GP Details

Present Medication

Medical History (Tick if Yes)

Arthitis Diabetes Cancer T.B Mental Health Asthma High BP Low BP Epilepsy Migraine Skeletal Problems Recent Surgery

Any other medical history or information I might need (eg. pregnancy...)

Present Ailment/Symptoms

What is your intention ?

I hereby agree, that the above is true to the best of my knowledge and that the following treatment is given to aid in stress reduction and relaxation and therefore allow the body to heal itself. I also agree that I have been advised to obtain a medical opinion should my symptoms continue.

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Individual
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I Am Woman
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Individual
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I Am Woman
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Samantha
Goddard

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@2025 - Samantha Goddard

Individual
Corporate Through To Creative
I Am Woman
My Story
Collaborations
Your Letters

Individual
Corporate Through To Creative
I Am Woman
My Story
Collaborations
Your Letters

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