Medical Form - Tibetan Medicine School

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Medical Form for Online Consultation

Please complete the medical form below, once processed, we will send you all the details regarding the consultation to the email address provided.

ONLINE CONSULTATION

in English language ( 35€ fee )with Spanish Translation ( 45€ fee )

PERSONAL INFORMATION

First Name

Last Name

E-mail

Phone number

Age

RESIDENCIAL ADDRESS

Street&Nr.

ZIP

City

Country of Origin

ARE YOU PREGNANT OR DO YOU SUFFER FROM ANY OF FOLLOWING CONDITIONS?

PregnancyCOPD (chronic obstructive pulmonary disease)CancerHepatitis B or CNeuritisHeart problemsCOVID 19Blood pressure problemsHIVAnxiety or any other mental health conditionAsthmaDiabetesThyroid problemsTuberculosisDependence on any drug or alcohol

TOPIC OF THE CONSULTATION

How did you find out about our school?

Internet

Social media

From a friend

Other

MEDICAL DISCLAIMER & INFORMED CONSENT
By accepting and contracting a consultation with our Tibetan medicine practitioners I accept the conditions and the exemption of medical responsibility. I acknowledge and understand that the Tibetan medicine practitioner must be fully aware of my existing medical conditions. I have disclosed all those medical conditions that affect me. It is my responsibility to keep the practitioner updated on my medical history. The information I have provided is true and complete to the best of my knowledge and belief. I have read the consent mentioned above and I accept.
Consent to the processing of personal data.

Location

Avd. Adeje 300 № 38, Playa Paraiso
Adeje 38678, S/C de Tenerife

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+34 657 26 21 82

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tibetanmedicine@atiyogafoundation.org

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