Let's get your pre-retreat consultation with Lilly booked...
Complete the form below and we will be in touch shortly
- STEP 1
Full address inc. Postcode
DATE OF BIRTH
NUMBER & AGES OF CHILDREN
HOW DID YOU HEAR ABOUT LIFE RIGHT (IF FROM A PERSON, PLEASE GIVE THEIR NAME)
Have you had both of your covid-19 vaccinations? (all those attending a Life Right Retreat are required to have had both covid 19 vaccinations)
YEARS IN CURRENT JOB
PREVIOUS OCCUPATION IF LESS THAN 2 YEARS
HEALTH DETAILS (PLEASE COMPLETE IN FULL)
NAME OF GP
Are you seeing a specialist of any kind at present?
If 'YES', for what are you seeing them for and what is their specialism?
WHAT MEDICATION ARE YOU CURRENTLY TAKING?
WHAT MEDICATION WERE YOU TAKING BEFORE BUT ARE NO LONGER?
BROKEN BONES IN THE PAST
ANY PREVIOUS ROAD TRAFFIC ACCIDENTS? (INC. DATES)
PLEASE LIST ANY OPERATIONS OR HOSPITALISATIONS IN LAST 10 YEARS (INC. DURATION)
ANY PREVIOUS X-RAYS
PLEASE DETAIL FROM CHILDHOOD TO PRESENT DATE ANY EVENTS, SITUATIONS, PEOPLE OR TRAUMA YOU FEEL MAY BE SIGNIFICANT IN HOW YOU ARE FEELING TODAY (WITH DATES IN A TIMELINE LIST) (inc. hospital visits or long periods of antibiotics)
PERSONAL INFO (CONTD)
DO YOU SMOKE
IF 'YES', HOW MANY PER DAY?
FOR HOW MANY YEARS?
DO YOU EXERCISE?
TYPE OF EXERCISE?
YOUR HEIGHT IN CMS
YOUR WEIGHT IN KGS
Please detail in this section what you would like help with on the retreat?
ARE YOU CURRENTLY EXPERIENCING ACHES OR PAINS? PLEASE DESCRIBE IN AS MUCH DETAIL AS POSSIBLE
Please describe in as much detail as possible, what we can help you with?
please type your name to confirm you have completed this form fully and not omitted any information
When you click SUBMIT, you will be taken to the payment authorisation page, where you will need to complete your payment card details