Appointment Request Form

Appointment Request Form New

(All appointment requests are subject to availability and confirmation)
Is this a first time booking or repeat appointment?
Full Name
Date of Birth

MonthDayYear
Gender
Phone Number
Format: +(000) 000-000000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address
example@example.com
Have you previously attended our facility
If Yes, state for which condition and when?
Current Ailments/Symptoms for which treatment is requested
Have you Experienced Acupuncture or any other Energy Healing Treatment before?
If Yes, which ones?

Other
Would you like more information on any of the available treatment options? Please tick which option(s) you would like to know more about.
Appointment Type
Select Which Treatment Option you require(N)
Select Which Treatment Option you require(R)
Please select which day you prefer. Final appointment date and time will depend on availability.
Booking Deposit Payable to confirm Appointment KShs 2,000/-. (This will be offset against your first consultation/treatment as applicable). (Mpesa Paybill 542542 A/c 01253). Enter payment confirmation Ref below. Treatment charges is KShs 4,000/- per session payable at each session. Please note all last minute cancellations (less than 24hrs) and no shows incur a no-show/cancellation fee of KShs 2,000/-.
Last Minute Cancellation (Less than 24hrs) and No Shows.
Please note all last minute cancellations (less than 24hrs) and no shows are subject to a cancellation/no show fee of KShs 2,000/-
Kindly also complete the New Client Registration Form after clicking the submit button.

Link is on the Thank You page.

Thank you and Hope to see you at the clinic soon.
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Preferred In Clinic Appointment Time (Nyali)
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Appointment Request Form New

Appointment Type