Appointment - Soma Clinic

We are getting your particulars here in the hope you do not have to fill up another form at the clinic.

Name *

First

Last

Phone *

For us to schedule appointments with you via whatsapp.

E-mail *

For us to send you electronic copies of invoices or other correspondences.

Home Address *

This is part of what we need in collection of particulars, so there is no need to fill up a physical form when you are here.

Date of Birth *

e.g. 12 Jul 1977 or 31 aug 2019 (this allows us to enter your age into the system).

Conditions:

Please elaborate here regarding your condition(s):

Modalities of Choice

Preferred Time Slot

e.g. Sat mornings, Mon/Tue/Fri lunctime 12-130pm, evening 6-7pm, monrings before 1130am

How did you come to know about our clinic?

If others, please elaborate?

Acknowledgements: *

I understand that the therapies received here are for the purpose of stress reduction, downregulation of the nervous system and working on health concerns like chronic health, pain, fertility, stress and burnout. I understand that the therapies here at Soma Clinic do not diagnose illness of disease and that the therapies are not a substitute for medical examination. I understand that Soma Clinic will take all reasonable precautions to ensure my safety and that I will not hold them accountable for any injuries sustained in the clinic.
I would like to receive info and updates from Soma Clinic and associated parties.

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