online booking Form

Secure Leech Therapy Consultation Form

We understand discussing personal health concerns can be sensitive. Please complete this form to help us provide personalized care. Your information will remain confidential.

Contact Information

Your Name (required):

Email Address (required):

Phone Number (optional):

Preferred Contact Method:

EmailPhoneNo Contact Required

Therapy Goals and Concerns

What are your primary goals for leech therapy? (Check all that apply):

Pain reliefImproved circulationInflammation reductionSkin rejuvenationFaster surgical recoveryGeneral wellnessOther

Specific Conditions or Areas of Concern

Please select the condition(s) or area(s) you want to address:

Gum health or dental issuesArthritis or joint painVaricose veinsMigrainesSkin conditions (e.g., acne, scarring)Women's health (e.g., hormonal balance, menstrual pain, intra-vaginal therapy)Men’s health (e.g., prostate support)Post-surgical recoveryChronic painDetox and general wellnessOther

Additional Details

Have you had leech therapy before?

YesNo

If yes, please share your previous experience:

Do you have any specific preferences or requirements?

Health and Lifestyle Information

Please share any relevant medical history:

Do you take any medications, including blood thinners?

YesNo

If yes, please specify:

Do you consume caffeine, alcohol, or smoke regularly?

YesNo

If yes, please provide details:

Do you have any known allergies or sensitivities?

Privacy Preferences

Would you like your details to remain anonymous during consultations?

YesNo

Appointment Preferences

Preferred consultation method:

In-personOnlineWritten communication only

Preferred dates/times for a session:

Consent and Agreement

I acknowledge that leech therapy is a complementary treatment and understand that additional consultations may be required.

Final Confirmation