T4H Low Cost Clinic (LCC) Referral Form

This form is to refer yourself or someone else to our Low Cost Clinic (£) held in the centre in SE23 between 10am and 3pm for physical treatments. Please fill out the following form to help us understand your physical condition and someone will be in contact with you. Fixed bookings need to be made.

Tick if you suffer from any of the following:
Tick if you suffer from any of the following:
Have you had a positive Covid-19 test?
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Are you pregnant?
Do you have a pacemaker?
Are you on any medication?
Are you registered disabled and/or have a life limiting condition?

© 2020 Therapy 4 Healing Registered in England No 7103929

120 Stanstead Road, Forest Hill, London. SE23 1BX

Tel: 020 8617 8820