Distance Healing Client Consent Form

Full Name *

Email *

Phone *

Address *

City *

Postal/Zip Code *

How did you hear about us? *

Current Medications & Dosage *

Are you currently under physician's care? If yes, what is name of physician?

Have you had Distance Healing before? (Yes or No) *

If yes, when was your last session?

Number of previous Distance Sessions

Do you have a particular area of concern? *

I understand that my appointment time is reserved for me. More than one appointment missed or cancelled without 24 hours notice, will be subject to a cancellation fee. I understand and release the practitioner from any/all liability from problems arising as a result of information not given or withheld.

I understand that Distance Healing is a simple, gentle, energy technique that is used for stress reduction and relaxation. I understand that Distance Healing Practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of licensed medical professionals. I understand that Distance Healing does not take the place of medical care.It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment i may have. I understand that Distance Healing can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

I understand that the information contained in this Consent Form will remain confidential and that it is gathered for treatment and administration purposes.

By my electronic signature, I acknowledge that I understand and agree to the terms contained in this Consent Form.

Electronic Signature