Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Do you suffer with TMJ Dysfunction? *

Yes

No

GDPR Client Consent Form: *

We will process any Personal Data you provide to us for the following purposes:(i) to provide you with the services you have requested;(ii) to contact you if required, in connection with your request, or to respond to any communications you might send to us;(iii) to send you newsletter, event alerts, information about product releases, service notifications and to communicate with you about relevant industry information and activities. This is only pertinent if you voluntarily sign up for this service. For the purposes of providing treatment at this workshop, Helen Baker at TMJ Massage Therapies may require detailed medical information. She will only collect what is relevant and necessary for your treatment. When you visit our practice, we will make notes that may include details concerning your medication, treatment and other issues affecting your health. This data is always held securely, is not shared with anyone not involved in your treatment. To be able to process your personal data it is a condition of any treatment that you give your explicit consent to allow the Practitioner, Helen Baker to document and process your personal medical data Contact details provided by you such as telephone numbers, email addresses, postal addresses may be used to remind you of workshop details, future appointments and provide reports or other information concerning the workshop or your treatment. Do you agree?

Yes

No

Do you agree to participate in an enrolement phone call if required?

YES

NO