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Client Health Form

New clients need to fill out the following form.

First Name

Last Name

Email

Phone

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate here as well as any medication you are on.

Next of Kin

Next of Kin Phone Number

What are your health goals? Be specific

Initials

I declare that the info I’ve provided is accurate & complete

Nga mihi. Thanks for submitting

The Study of Ancient Healing
through the Mauri of Rākau

By Rongoā Māori Healer Joanne Hakaraia

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RĀKAU Rongoā Mauri Healing Limited, 2016

ALL RIGHTS RESERVED 2023

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