Tynemouth's premier chiropractic care facility

Massage consultation - background information




















Thank you for taking the time to fill in this form. Please acknowledge ALL the following; if you don't, we cannot accept you as a patient.


  • • The above information is to the best of my knowledge true and correct.
  • • I have read the Naturally Chiropractic Privacy Policies, the Consent for
    Care & Data Collection     and the Expectations of Healing pages.
  • • Having read these documents, I confirm that I wish to proceed with care at Naturally Chiropractic.
  • • I also agree that, should it be necessary, you may contact my GP at: 


If you are filling in this form on behalf of another person/under 18, please supply the following:

Your health

Our massage therapist will need some background information to ensure you get the best possible care.


Please fill in this form before your visit. We also ask all clients to read the following documents and confirm you have done so:









Please note that by submitting this form you are giving us permission to contact you using the methods listed above. Your details will be held on our database but will not be passed to third parties at any other time.
You will also be added to our monthly email newsletter, but you can unsubscribe at any time.