New Patient Form First Name * Last Name * Email * Address * Used only if you would like us to contact your GP. Address 1 Address 2 City state Zip Code Country Do you have any pre-existing medical conditions or concerns that we should be aware of? I consent to a verbal history, relevant clinical assessment and, after a report of findings, treatment if deemed necessary * We always explain everything before our history, assessment and treatment. We will never do anything without your consent and you can decline or revoke consent at any time. YesUnsure I consent to receiving emails from Summit Wellbeing regarding my treatment, exercise program and clinic news * We never share your information with anyone and we only ever contact you with relevant clinical information and treatment advice. YesNo
