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> Complimentary Therapy Referral

Mustard Tree: Complimentary Therapy Referral

You can either be referred by a Mustard Tree member of staff or you can self-refer. A member of staff will then contact you to arrange an appointment.

Please do not enter any healthcare information on this form.

Personal details

Note: Questions marked by * are mandatory

*This is a mandatory field. First name:

*This is a mandatory field. Surname:

*This is a mandatory field. Date of birth:

*This is a mandatory field. Contact number (including area code):

*This is a mandatory field. Email address:

*This is a mandatory field. I am happy for a message to be left

not at all
on answerphone
with a member of the household

*This is a mandatory field. GP name:

*This is a mandatory field. GP address:

*This is a mandatory field. I am the

carer
patient
relative

*This is a mandatory field. Reason for referral (e.g. for relaxation, stress relief, help with pain etc.)

Do you have problems with any of the following? (tick all that apply or leave blank if not applicable)

Any allergies - apart from skin allergies
Any other health problems - e.g. epilepsy, diabetes, unstable/high/low blood pressure
Bone/joint problems - e.g. Arthritis, rheumatism, fractures, osteoporosis
Breathing problems - e.g. asthma, bronchitis, breathlessness
Circulatory problems - e.g. Varicose vein, DVT, PE or history of clotting
Contact lenses/Prosthesis/Implants
High fever
Loss or altered sensation in hands or feet
Lymphoedema
Mobility problems
MRSA/CDIF
Nerve problem - e.g. sciatica, pain
Open wounds
Pregnancy, miscarriage, PMT, menstrual problems, menopause
Skin problems - e.g. allergies, eczema, dermatitis or skin sensitivity
Stress problems - e.g. anxiety, insomnia, depression, headaches
Urinary problems - e.g. cystitis, thrush

Diagnosis:

The following questions are only to be filled in if requesting the appointment as a patient (if carer or relative, please skip these questions and send the form)

Consultant

Are you currently undergoing treatment?

Treatment

Chemotheapy
Other
Radiotherapy

If other, please specify

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