Holisticare Treatment Bank Nomination Form

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Holisticare Treatment Bank Nomination Form

Please use this form to tell us about someone that you know would benefit from our treatment, but who isn't in a financial position to access it. If they are accepted, they will receive 2 x 1 hour treatments at Holisticare.

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* Indicates required question

Your name *

Your answer

Your phone number *

Your answer

Your email address *

Your answer

Your nominee's name *

Your answer

Your nominee's phone number
*

Your answer

Your nominee's email address
*

Your answer

Does your nominee know that you have given us their details for us to contact them? *

Yes

No

Please tell us why you are nominating them *

Your answer

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