Forename:          Surname:

Have you had a treatment before from Eliz?      Yes No

(if yes, answer next question otherwise carry on to next question)

If you want to leave feedback on the treatment you received:

Is there any treatments which are not listed in therapy and would like to ask about:  

Treatment name:

Any other questions or information?

if there is any other questions or feedback you would like to leave , please state below: