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Client registration form

Personal details

First Name*

Last Name*

E-mail*

Password*

Confirm Password*

Mobile No.*

Date of Birth

Referral Source*

Employer paying for your sessions*

Headroom's Terms of Use*

I have read and here-by accept the terms of Headroom's Client Agreement, Privacy Policy, Acceptable Use Policy and the provisions of POPIA & PAIA Manual.

Communications*

I consent to receive ad-hoc client communications, newsletters and special offers from Headroom. I understand I can subscribe at any time.

Gender

MaleFemale

City*

Emergency Contact Name

Emergency Contact No.

Medical aid details

Medical Aid Communications Consent

I hereby grant Headroom permission to communicate directly with my medical aid in case of queries. I acknowledge that the responsibility to submit my claims is mine.

Medical Aid Membership No.

Medical Aid Name

Dependent Code

Only fill in if you are not human

Client registration form

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