Secrenase Registration Form

Secrenase Registration Form

This form may be emailed or printed and sent by post or fax

* Required fields
Name *
E-mail Address *
Your Full Address *
Postcode/Area Code *
Child's Weight in Kilo's *
Child's Date of Birth (dd/mm/yyyy) *
Telephone No: (Inc country code) *
Fax No: (inc country code)
Preferred Method of Contact *
Your child's GP Details (Optional)
Would you like your Child's GP Informed? *	Yes No Maybe later
At what age did you first think your child had a problem? *
Has your child been diagnosed with Autism/Asperger's *	Yes No
Are any other members of your family or extended family Autistic/Asperger's? *	Yes No Not Known
Your Child's Full Name *
Has your child had a hearing test? *	Yes No
Has Your child had a stool analysis done? *	Yes No
Has your child had a hair analysis done? *	Yes No
Has your child had a urine analysis done? *	Yes No
Has your child had any bowel investigations? *	Yes No
If no, and you would like to arrange for any of these tests - please complete the online request form to arrange these
Has your child had any other tests? If so - please give brief details *
If you child sensitive to any Gluten/Casein/Wheat or Milk Products? *	Yes No Not Known
Does your child have any other allergies? - If yes please give details
Is your child on any form of diet? *	Yes No Sometimes
If you child is already receiving other forms of treatment please give brief details *
Does your child have regular soft bowel movements? *	Yes No Sometimes
Please give brief details of your child's main problems *
I being the parent/guardian of the above named child consent to treatment with Secrenase *	Yes

I have read and agree to the Privacy Policy *

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