Booking Form

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  - Tulbagh
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HEA

Booking Form

Please complete the following.
Only check a box if it is applicable.
Max of two sessions per day.

* Indicates required field

Name *

First

Last

Email *

Only relevant to the current issue: Have you seen a medical practitioner *

Yes No Have you had medical tests performed Have you undergone surgery Do you have medical implants Neck pain (ltd range of motion) Shoulder joint pain/ frozen shoulder Upper arm Sciatica Carpel tunnel (hand or wrist pain) Hip Lower back Swollen joints Back aches Foot pain Hand Pain Other

did a medical doctor make a diagnosis? *

What are you curranty experiencing *

issue to address *

WhatsApp to confirm you have submitted an enquiry 0789 26 8151 *

WhatssApp me to inform me that you have applied for an appointment

Submit

HOME
Body work
VFRT
Disclaimer
Gallery
- Pelvis
- Gelding scar
- Break Out
- Cody
- Hally
- Molly
- Molly meeting 3
- Main Gun
- Sweetness
- Tik Tok
- Flaunt It
- Funnies
- Fun >
  - Tulbagh
Contact us
HEA

Booking Form

Please complete the following. Only check a box if it is applicable.​Max of two sessions per day.

Please complete the following.
Only check a box if it is applicable.
Max of two sessions per day.