Best Phone Number
Best Email Address
Date of Birth
Emergency Contact Name & Number
How did you hear about us?
What Service are you here to receive?
Have you received this service before?
If Yes, what was your experience?
Are you comfortable on your back and front?
Are you comfortable with light touch during your session
Are you allergic to any essential oils or fragrances?
Are you currently under medical supervision?
If Yes, what condition(s)
Please list all Homeopathic, OTC & Rx
What is your goal for this session?
Is there anything else I should know?
Client Rights & Responsibilities
Your Digital Signature
Regina Ann Practitioner Disclosure
Rich Bentz Practitioner Disclosure