Tilmeldingsskema til Projekt. .pdf

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Original filename: Tilmeldingsskema til Projekt..pdf
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Date:
Diagnose: (Her bør læges eller skoles diagnose anføres)

Barnets navn:
Alder:
Mors navn:
Fars navn:
Adresse:

Tel:
Mail:
Relevant information: F.eks. familie forhold.

Diagnose & symptomer :

Hvornår er situation opstået:

Medicin:

Anden terapi eller behandling:

Skole:

Dato forældrekursus :
Depot / Ansigt
Ansigt:
Hænder:
Fødder:
Andet:

International Institut for Reflex therapy, Lone Sorensen, Barcelona, Spain
0034 678769550

www.reflexologiafacial.es

www.temprana.org

sorensensistem@gmail.com


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