Regform2 Personal Information Full Name * Gender * Male Female Date of Birth * Address * Email * Mobile Tel. * Service Required * Select Service Hijamaah - Cupping Therapy Ruqyah - Quranic Healing Why are you seeking treatment? Confirmed medical conditions * Past/Present prescriptions Allergies Emergency Contact * Symptoms (Tick all that apply) Lack of spirituality Doubts in religion Lethargy in worship Uncontrollable yawning Inability/aversion to reciting/listening to Quran Extreme fatigue Feelings of fear or panic Forgetfulness Sudden hair loss Sudden weight gain/loss Extreme mood swings Desire for isolation Nightmares Recurring dreams Persistent negative thoughts Physical pain Sudden change in behavior/thoughts Terms & Conditions * I agree to all the terms and conditions including data protection, recording sessions, fees policy, cancellation policy and Hijaamah/Cupping therapy terms. I have read and agree to all terms and conditions. Submit AFA Hijamah Training Registration Please kindly complete this form if you wish to register for the Hijamah Training Course onsite in Sheffield. Email * Full Name * Age * (must be over 18 years) Contact Number * Health & Learning Do you have any additional learning needs? * Yes No Do you have any health conditions which cause problems with manual dexterity? * Yes No Do you have any diagnosed Blood related health concerns? * (We do not train Hemophiliacs) Yes No Have you ever had a seizure or suffering from Epilepsy? * Yes No Do you have any allergies? * Background & Experience Do you have any Qualifications or Training in Human Anatomy and Physiology? * Do you belong to any professional medical organisations? * Yes No Have you studied with Al Fatiha Academy before? * Yes No Have you ever suffered from Jinn Possession or Sihr Affliction? * Yes No Is there anything you wish to share with the Instructor? * Declaration I understand by submitting this form that I am declaring that I'm in good health and do not know of any reason why I wouldn't be a suitable candidate to learn and practice Hijamah on my family and friends. * Submit Registration
