In-person Module Preparation Form

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Health & Responsibility Consent Form for Hunyuan Qi Therapy Program

Name *

First

Last

Passport Number *

Address *

Contact in Case of Emergeny

Name *

First

Last

Phone *

Current State of Health

Please select what's applicable. *

Healthy
Pre-existing medical conditions / illnesses

Please inform us about any medical condition that you may have, so in case of emergency we can inform relevant doctors about it.

Previous State of Health

Please select what's applicable. *

I have always been healthy.
I have been suffering from previous medical conditions / illnesses.

Please specify any previous medical conditions / illnesses:

Medication

Are you taking chronic medication? *

Yes
No

Please specify any chronic medication:

Last Checks

Did you take care of the following? *

I booked my room at the accommodation.
I informed who organizes the transfer about my arrival and departure times.
In case needed, I arranged travel insurance.

Acknowledgement

I acknowledge: *

that I am not allowed to take any recordings of the practices and theories shared.

By signing I accept the Terms and Conditions *

OK

Hunyuan Qi Therapy

Become a certified health & well-being coach based on the methods taught at the world’s first medicine less hospital. It’s an educational program with flexible learning modules. Learn from Master Yuantong Liu, one of the world’s leading Zhineng Qigong Masters.

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