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To improve our efficiency and save the planet we are moving some of our forms online. Please help us speed up your appointment with us by filling in this form prior to your visit. If for any reason you can’t fill this form in, a paper copy will be given to you on your arrival in reception. Please allow time prior to your appointment time to fill in this form.


New Guest Questionnaire

    We’ll only contact your GP if necessary. If you don’t want us to contact your GP, then don’t provide their details

    Where would you put your current stress level on a scale of 1 to 10 where 1 is low and 10 is extreme


    Where would you put your current pain level on a scale of 1 to 10 where 1 is low and 10 is extreme


    Fee structure and data protection

    The full fee (£40) is charged for missed appointments. £20 late cancellation fee if less than 24HRs notice given.

    The clinic will store your notes and files on paper and electronic format. All information is treated in the strictest confidence and only handled by the clinic staff directly involved in the consultation and data processing of your case. Original notes belong to Lushington Chiropractic. Copies can be made at your request and expense.

    By check this box and clicking submit I acknowledge am digitally signing this form:

    Are you in pain?

    We can help
    Call your Eastbourne Chiropractor on
    01323 722499