New Client Information Form
Energetic Apothecary - Reiki For Wellness - Tammy Schoolcraft

Welcome!
I am excited to be working with you! Please fill out the following information and consent to treatment prior to your appointment.
First and Last Name *
Email Address *
I am interested in the following services... *
Required
Date of Birth *
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Current Age *
Phone Number Best to contact you and receive text appointment confirmations *
City, State Where you live *
How did you hear about me or whom may I thank for a referral? *
Are you Currently under the care of a physician? *
What are your goals for our session together? *
Current Medical Conditions Physical or Emotional that I should be aware of *
Check any of the following that apply to you *
Required
If you Checked any of the above conditions or "other" - Please provide details and approximate dates where applicable. If None answer N/A *
Do you have any specific area of concern, or anything else that you would like for me to be aware of before our session together?
COVID-19 Pre-Screener and Agreement
• I have not knowingly been in contact with anyone diagnosed with Covid-19 in the past 2 weeks.
• I have not had any of the following symptoms in the past 2 weeks: Fever, Cough, Sore Throat, Diarrhea, loss of taste, or smell.
• I acknowledge I am receiving treatments knowing that social distancing cannot be adhered to during my session.
• In the event I test positive for Covid-19, I will notify my practitioner as soon as possible.

COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely
contagious and is believed to spread mainly from person-to-person contact, although there is much about it that is unknown. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing. Your practitioner has put in place preventative measures to reduce the spread of COVID-19; however, your practitioner cannot guarantee that you will not become infected with COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by receiving treatments where social distancing is not possible and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my energy healing appointment. On my behalf, I hereby release, covenant not to sue,
discharge, and hold harmless my practitioner, their establishment, and any interested parties from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of my practitioner or the establishment where my services are received, whether a COVID-19 infection occurs before, during, or after participation in any session.

By Signing and submitting below you agree to these terms
Treatment Consent
The treatments provided are not intended to replace the advice or care of a licensed physician. Treatments with my practitioner are not intended to diagnose, treat, or cure disease, but to support the body’s natural ability to heal itself. By signing this form, I understand that there can be a detox effect from energy/body-work and if it lasts greater than 4-5 days, I should contact my practitioner and/or a licensed medical professional.

There are no known contraindications for Reiki, however, Biofield Tuning is a specific energy adjustment and contraindicated in the following: Pacemaker, Concussion less than 6 months, Cancer or Terminal Illness, Pregnancy, and Implanted Pain Stimulators. - By signing below you are indicating that you have read and understand these contraindications and have answered all of the questions above to the best of your ability.

Under 18 years of age - parent please sign consent to treat below
Signature *
Date *
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