Client Protection questions

First Name

Last Name

Date of Birth

Address Line 1

Address Line 2

City

Postcode

Height (in Metres)

e.g. 1.65M

Weight (in Kilograms)

e.g. 95kg

Waist Measurment (in Centimetres)

e.g. 65cms

Are you a smoker?

Yes

How many per day?

What type?

Any other health issues If any, please can you provide details of what the condition is, when it was diagnosed and if on medication, please confirm what this is and how often it is taken

Do you have any of the following?

Diabetes

High/Low Blood Pressure

Diabetes

Please provide your last 2 diabetic readings

Reading 1

Reading 2

Date of reading 1

Date of reading 2

High/Low Blood Pressure

Please provide your last 2 blood pressure readings

Systolic 1 (higher number)

Diastolic 1 (lower number)

Diastolic 2 (lower number)

Date of reading 1

Date of reading 2

Any family health issues and what age diagnosed if any? (enter NONE if none)

Current Doctors details (name, address and contact number)

Bank Details

We will contact you to obtain bank details when the application is ready to start.

Health Information

We will use your personal data to understand your personal situation, financial aims and objectives to enable to us to provide appropriate financial advice in line with our Privacy Policy.

JPA

Paraplanning &
Admin Services

JPA

Paraplanning & Admin Services

Client Protection questions