Client Information Form

Novesprit client background form

Please complete the details below

Are you taking any prescribed medication for a medical condition?

Have you undergone surgery in the past 6 months?

Is there any other medical issue which may affect your state of mind or emotional wellbeing?

If you checked any of the boxes in the first list of conditions above, please confirm whether you have consulted, or are presently under the care of a medical professional:

I declare that the above details are correct to the best of my knowledge. I understand that any medical condition must be treated by an appropriate medical professional. By completing this form, I agree that all processes and activities undertaken with Novesprit or any of its representatives do not offer or provide any type of diagnosis or medical treatment. Novesprit cannot guarantee a specific result or outcome and does not provide remedies for any a physical issue requiring medical treatment.