REGISTER

Riverview Wellness Centre

Thank you for your interest in Riverview’s 7-day On-site Diabetes and Hypertension Reversal Program®. Please fill out the form below to apply for the programme. We’ll contact you to confirm your application.

A deposit of K500 is required to complete this application, and you will be asked to make this payment when contacted.

First Name

Last Name

Telephone Number(s)

Date of Birth

Gender

Male Female

Choice of Accommodation

Standard Chalet K8,500 Standard Lodge K9,700 Premium Lodge K13,100

Health

I have these conditions (click all that apply)

Diabetes Type I Diabetes Type II Prediabetes Hypertension Asthma Arthritis Cancer Depression Edema Emphysema/Lung Disease Fibromyalgia Hearing Loss Heart Disease High Cholesterol Inflammatory Bowel Disease Kidney Disease Lupus Neuropathy Osteoporosis Stress/Anxiety Stroke/TIA Vision Impairment

Please list any other health challenges not shown above

Does someone help you with daily tasks, such as dressing, bathing or medication?

Yes No

How did you hear about us?

ADDRESS

FARM 85A CHIKANKATA DISTRICT, KAFUE, ZAMBIA

LODGE TEL: +260 970 805653 WELLNESS: +260 977 668924

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