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Client Registration
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* Indicates required question
Email
*
Your email
Clients First Name
*
Your answer
Client Last Name
Your answer
Phone Number
*
Your answer
Address
Your answer
Next of Kin
*
Your answer
Next Of Kin Contact Number
*
Your answer
Date Of Birth
*
MM
/
DD
/
YYYY
If client is under 18 years of age has parent/guardian given consent?
*
Yes
No
Not Applicable
If client is under 18 years of age please provide names of parents/guardian:
Your answer
Pregnant women or those who have given birth within the last 10 days are required to obtain written consent from their primary caregiver.
*
Not Applicable
Written Permission Obtained (Please supply a copy)
Written Permission Requested (Please forward prior to appointment)
Waiver
What are your reasons for seeking healing?
Your answer
Are you taking any prescribed medication? Please specify:
Your answer
What is your doctors name and contact number? (If applicable)
Your answer
What are your current challenges on your spiritual journey?
Your answer
What are your biggest aspirations on your spiritual journey?
Your answer
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