Your Last Name:

Your First Name:

Your Email:

Your Telephone Number:

Your Telephone Number (Mobile/Other):

Gender:
MaleFemale

Enter your Emergency Contact Name:

Enter your Emergency Contact Number:

Select Relationship (required)
—Please choose an option—ParentWifeSpouseRelativeFriend

Please Answer the Following Questions
1 What visit are you making to Orena? :
FirstSecond

Other Visit:

How did you hear about Orena?:
Social MediaReferralOrena Event

Other:

What services are you having today?:
Automated TestingBody Mass Index (BMI)Body Impedance Analysis (Not taken with a pacemaker)Blood PressureBlood GlucoseHemoglobinCholesterolTemperatureBlood OxygenUric AcidPeak FlowTotal Body AssessmentMeal PlanExercise PlanPersonalised Health Plan

Booking Date:

Consent Agreement

I hereby request and give my consent to Orena to perform wellness health tests on me. I understand that my session(s) with the Orena Coordinator cannot substitute for medical care, diagnosis and/or treatment from a medical professional.

I understand that all blood related tests generate rapid test results. Orena will keep all communications and records confidential. Information may be used for research purposes, but individual results will not be disclosed.

I Consent:
YESNO