Client Registration Form

Consultation Registration 咨询注册

If you like to consult for your health issues, please fill out the form below and sign it. 如果你需要咨询健康问题，请先填表注册并签字。
Name 名字*

First Name 名Middle NameLast Name 姓
E-mail 电子邮件*
Gender 性别*
Date of Birth 生日*

MonthDayYear
Contact Number 电话:*

Area CodePhone Number
Address 住址:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current Health Problems (condition, location and duration) 需要咨询的健康问题*
Signature （签字）: By signing this, I understand that this is not a medical diagnosis or treatment for any diseases but a consultation for the purpose of helping me improve my health and wellness. I understand this is not a substitute for medical diagnosis or treatment which I will contact my physician as needed. 通过签字，我明白这不是医学诊断或者治疗任何疾病而是健康咨询服务，目的是为了改善我的健康状况。我明白这也不取代所需的西医诊断和治疗，如果需要我会联系西医医生。 *

Clear
Should be Empty:

Consultation Registration 咨询注册