TestReg

Please fill out the form to register with Back Fit Clinical Therapies, giving as much information as possible. Once you have filled all the fields to the best of your ability, press the SUBMIT button at the end of the form. All the information will be sent to me, Elizabeth, at hello@backfit.co.uk. I will print it on paper for safe keeping and the computer record will be deleted, so none of your private information will be kept, except in my confidential files in a locked cabinet.

Please list your medications

Medication

Dosage

How Often

Family History. This can be a sensitive are. If you do not wish to complete this question, please skip to the next one.
Otherwise, please write if your parents are alive, what their health is, or if they are deceased, please write at what age they passed and their health before they passed.

Thank you so much for filling out this form. It will be encrypted and securely sent to me. I will print it on paper for safe keeping and it will be deleted from the computer.
There was an error trying to send your message. Please try again later.
There was an error trying to send your message. Please try again later.