Register as Client

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 unsubscribe 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

Register as Client

Client registration form

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