Vision Exercise Physiology

Show Holiday Scanning March 28th

Client 1

Client Details

Client First Name

Client Last Name

Date of Birth

Gender

Email Address

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Enter the password that you would like to use for your new account.

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Home Phone

Mobile/Cell

Address

Address 1

Address 2

Suburb/Town

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Zip/Postcode

Health and Fitness

Do you have any injury concerns?

Do you have any medical conditions?

Training Dates

From 06-Mar-2019 to 28-Mar-2019

Training Days & Times

Please select up to 1 sessions.
Once a time slot is full you will be asked to make another choice.

FULL	Thursday, 28-Mar-2019	09:00 AM	to 09:20 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	09:20 AM	to 09:40 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	09:40 AM	to 10:00 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	10:00 AM	to 10:20 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	10:20 AM	to 10:40 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	10:40 AM	to 11:00 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	11:00 AM	to 11:20 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	11:20 AM	to 11:40 AM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	11:40 AM	to 12:00 PM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	12:00 PM	to 12:20 PM	14 Ipswich Street	Show Holiday Scanning March 28th
FULL	Thursday, 28-Mar-2019	12:20 PM	to 12:40 PM	14 Ipswich Street	Show Holiday Scanning March 28th

DISCLAIMER:
Payment required at time of booking. You may be eligible for a private health rebate through your private health fund. We can issue an invoice after payment for you to use to claim your rebate upon request. DEXA scans occur at our Range Health Clinic, located at 14 Ipswich Street.

Agreement

Signed

Date

/ /

Payment Method

Payment is non-refundable.

Cost

$50.00

Cost Per Person

$50.00

Total Cost

Group Discount

Grand Total

Credit Card (Ezidebit)

Please mail this form with a payment attached to: "Vision Exercise Physiology, 324 Hume Street, Toowoomba QLD 4350"