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Registration & Disclaimer Form for Reiki Session
Your information is kept confidential and used only for the purposes of understanding your needs as an individual and to reach you in the event of class changes or cancellations.
Full Name: *
Birthdate *
Email *
Address *
Phone number *
Emergency Contact Name *
Emergency Contact Number *
How did you hear about us? *
Medications/Remedies/Supplements & Reason for Taking: *
Significant Accidents/ Injuries: *
Below, Please Describe What You Would Like To Accomplish With These Treatments: *
Reiki Session Options:
Column 1
$40 Chakra Balancing for 30 Minutes
$60 Reiki Healing for 60 Minutes
$45 Distance Reiki for 60 Minutes
$200 Reiki Package for 4 Sessions
$300 Reiki Package for 6 Sessions
Date for Reiki Appointment *
Payment must be in advance : E-transfer to *
I, (print name) consent to treatment for myself (or my minor child) (print name), and understand that the services provided by the practitioner GAYATRI PATHAK is intended to enhance relaxation and increase communication within my body.

I understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan.

I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided.

I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. I do, however, give the practitioner consent to use my case history and results without using my name. I understand that only the practitioner GAYATRI PATHAK will have access to information in my file to enhance my healing.

I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the practitioner GAYATRI PATHAK and the facility/location where the services are provided.

I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct. I agree to pay for distance sessions, should I request them.
Signature & Date: *
| Yoga4U |Gayatri Pathak|647-628-8241| | 13 Bonavista Drive, Brampton ON L6X 0N2|
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