Medical / History Data

Are you wearing any implantable medical devices? If yes, what are those medical devices?

Are you currently taking any medications? If yes, list them below:

Were you previously hospitalized? If yes, please indicate when and why:

Did you undergo any surgery in the past? If yes, please indicate the name and location of the surgery: *

Payment Policy

Full payment must be paid on all treatments and all services before any bookings are confirmed. PayToday, Pay 2 cell 0814417900 OR into the account: MEKENIFICENT WELLNESS CC FNB Acc #: 62245822483 Branch: MAERUA MALL Branch code. 282273 Ref: your name or number.

Authorization

• I confirm that all information given in this form is true, complete, and accurate. • I released this organization for any responsibility in case of accident, illness, or injury. • I acknowledge that no assurance was offered about the outcome.