Amanda Brooks D.C., BSc. (Chiropractic), Dip. M.E.S.K., M.F.H.T., E.C.P.
To give me as much information as possible please fill in this form and send to 47 Bucknell Road, Bicester, Oxfordshire OX26 2DE along with your house plan.
/Name:
Address:
How did you find out about me: / Contact telephone numbers:Email address: / Contact mobile no:
How many people live in your home and what are their full names:
How long have you lived in your home?
Do you have any cordless phones? If yes how many and where are they?
Do you have wi-fi? If yes where is it placed in the home?
Do you live near any electrical substations? Mobile Phone Masts? Electricity Pylons?
If so how far away are you from them?
Please read and sign the following statement:
I understand that Amanda Brooks does not give anymedical diagnoses and that it is my responsibility to consult my GP about any medical problem that I am aware of or may become alerted to in the course of the house energy clearing session.Signed: Date:
Your personal details will NOT be sold to third parties.
I would like to pay £245* by cheque,made out to Amanda Brooks.
I have paid £245* through the website usingPayPal.
You may use this option to also pay by credit card or alternatively you can enclose your details below.
I would like to pay £245* by credit card:
Type of credit card(Please tick which card used) / Visa Mastercard
Credit Card No.
Expiry date
Card verification number
(last 3 digits on signature strip)
Name as it appears on card
Signature / ......
These details will be destroyed once payment has been taken.
* The cost for this service is usually £425 but if your payment, Healthy House Questionnaire and house plans are with me by 31stDecember2018then you only pay £245.
Consent Form as per General Data Protection Regulation Requirements
(Please complete all sections)
Database
I, hereby, give / do not give (please delete as appropriate), permission for Amanda Brooks, of Find Your Inner Harmony, consent to keep the following records on a secure database, which is only accessible by Amanda Brooks, and her employees, and is never shared with any other individual or company.
Data that will be held on said database will be your:-
Name / Address / Telephone Number / Skype Name / Email Address
These will be kept there so that Amanda has an easy contact list in case of emergency re booking or appointment issue.
It is understood that your case files will not be held on any database, they will be kept in a secure location and you can request a copy of them at any time.
E-news
I, hereby, give / do not give (please delete as appropriate), permission for Amanda Brooks, of Find Your Inner Harmony, consent to add my name to her E-News that she publishes through various times of the year, to keep clients up-to-date with health news, opening hours, new tools to help with client’s issues, offers and price changes, with the right to unsubscribe at any time. The details will be held on a secure server and will use the following personal data and is never shared with any other individual or company.
Name / Email address
Length of time your Case Files are held for.
I, understand that if I have not received energy work from Amanda Brooks, in the last seven years, then my records will be destroyed using a cross Cut Shredder / Security Level P-4. I understand that I can ask for the return of my records at any time during that seven years, however, a copy will need to be kept in order, for Amanda Brooks to comply with her Professional Insurance guidelines.
Signed ……………………………………………………………………………………………………………
Print Name …………………………………………………………………………………………………….
Date ……………………………………………………………………………………………………………….
Amanda Brooks Tel: 07938 851750 Email:
47 Bucknell Road, Bicester, Oxfordshire OX26 2DE