Consultation Form - Abdel Kader Cupping-holistic therapies to treat a wide range of common health problems

Name

First

Last

Date Of Birth / Age

First

Last

Address

Mobile Phone

Email

Emergency Contact Details

Occupation

Currently Receiving Medial Treatment?

If yes, please give details:

Are you taking any blood thinning medication?

If yes, please give details e.g Warfarin – Heparin

Have you had any Hijama( wet cupping) before?

Reasons for wanting Hijama Treatment e.g.Sunnah,Medical,etc

Please choose options if you have any of these

For Female Clients Only

Select Package

Client Consent: I take fully responsibility and i give my consent to the therapist to perform Hijama