top of page
Log In
Menu
Close
Home
Foundation Mission
Upgrade Client Form
Book Now
Privacy Policy
Terms & Conditions
RASHA UPGRADE CLIENT FORM
First Name
Last Name
Phone
Email
Do you have a Pacemaker?
*
Yes
No
Are you currently undergoing chemotherapy or radiation treatments?
*
Yes
No
Do you have a history of seizures?
*
Yes
No
What are you hoping to address with your RASHA upgrades?
I declare that the information I’ve provided is accurate & complete.
I accept terms & conditions
Submit
Thanks for submitting!
bottom of page
