Full name:




Your holiday start date:

Your holiday end date:

What treatment/s would you like?:

Or please list treatments here:

Preferred dates:

Lodge staying in:

Doctors name:

Surgery address:

Known medical conditions:

Are you currently taking any medication:

Treatments had/having:

Date of treatment:

I declare that the information I have given is correct. I have been fully informed about the treatment and am happy to proceed: