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 conent to treatment prior to your appointment.

First and Last Name *
Your answer
Email Address *
Your answer
I am interested in the following services... *
Required
Date of Birth *
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Current Age *
Your answer
Phone Number Best to contact you and receive text appointment confirmations *
Your answer
City, State Where you live *
Your answer
How did you hear about me or who may I thank for a refferral? *
Your answer
Are you Currently under the care of a physician? *
What are your goals for our session together? *
Your answer
Current Medical Conditions Physical or Emotional that I should be aware of *
Your answer
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 *
Your answer
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?
Your answer
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 you ability.

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

Signature *
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Date *
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