Signup A Client First Name *Last NameDate of Birth *Address *Sex *MaleFemaleMarital Status *Ethnicity *Weight *Height *Color of Hair *Color of Eye *Occupation *Employer *Mobile Contact *Other Contact *Emergency Contact *Relationship *Contact *Contact *ContactDo you use any equipment (Such as a walker or wheelchair) to assist in your daily life? *YesNoDo you have joint pain? *YesNoHave you fallen in the past 6 months? *YesNoDo you have difficulty with balance or walking? *YesNoAre you on any medication? *YesNoTAKE NOTE OF THE FOLLOWING People who have battery operated implant ( eg. pace maker) should never use DETOX MACHINE Anyone who has received an organ transplant should never use DETOX MACHINE Pregnant woman or nursing women should never use DETOX MACHINE Children less than 8 years old should never use DETOX MACHINE People who have low blood sugar should not use DETOX MACHINE Information Disclosure and Consent FOH will provide you with the care plan. If you decide to receive care otherwise, you will be asked to sign a closure form in the order of your request. I read and agree to all the above (information).Print Full Names *Name of Nurse Doing The Registration *Nurse ID number *To Complete Registration Please Choose Any of The Packages Below And Make Payment GHs 290 for 90 days GHs 429.99 for 6 months GHs 709.97 for 12 months Client Payment Details 0201070120 FEEL OF heaven manufacturing Ltd 0553494231 Wumbei Nchibi Thomas Momo Name *Momo Number *Submit Form
