All Contents of this form are Strictly Confidential and will NOT be shared with anyone except the client and practitioner without express written consent of both parties.
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?
For Therapy Clients:
Are you comfortable on your back and front?
Are you comfortable with light touch?
Are you comfortable being treated without being clothed covered by a therapy sheet?
Are you allergic to any 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 Full Name