Registration Registration Please enable JavaScript in your browser to complete this form.Full Name *Gender *MaleFemaleDate of Birth *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeEmail *Mobile Tel. *Please select the service you require: *Ruqyah - Quranic HealingHijamaah - Cupping TherapyPlease provide information on why you are seeking treatment (include information on symptoms, events, feelings, thoughts, blockages in life etc.)Please list any confirmed medical conditions (state NONE if not applicable): *Please list any past or present prescriptions (state NONE if not applicable):Please list any allergies (state NONE if not applicable):Please provide the name of a person we should contact in the event of an emergency: *Please provide the contact telephone number of a person we should contact in the event of an emergency: *Please state the relationship of this person to you: *Please tick any/all that apply to you:Lack of spiritualityDoubts in the religionLethargy in worshipUncontrollable yawningInability/aversion to reciting/listening to QuranExtreme fatigueFeelings of fear or panicForgetfulnessSudden hair lossSudden weight gain/lossExtreme mood swingsDesire for isolationNightmaresRecurring dreamsPersistent negative thoughtsPhysical painSudden change in behavior/thoughtsI agree to all the terms and conditions as set out by the Ruqyah Resort Clinic, which include, but are not restricted to: *Holding personal information of mine in line with the data protection actSessions may be recorded (audio/video) and may be used for marketing/educational purposes (Faces will be blurred & voices will be changed to protect identity)No more than 2 persons will be accompanying me to the sessionFees are payable upfront via the online booking appCancelled appointments will not be refundedI understand that Hijaamah/Cupping therapy is for physical/health reasons only For a full list of terms and conditions Click hereAgreement *I have read and agree to all terms and conditions (after submission you will be redirected to the booking app)MessageSubmit
