#1

Name

#2

Email Address

#3

Phone (Cell)

#4

Can you receive text messages here?

#5

Address

#6

Date of Birth

#7

Occupation

#8

Emergency Contact

#9

Phone (Emergency Contact)

#10

How did you hear about the training

#11

Do you have any difficulty lying on your front, back, or side?

#12

If yes, please explain (difficulty lying)

#13

Do you have any sensitivity to fragrances, oils, lotions, or ointments?

#14

If yes, please explain (sensitivity)

#15

Do you have a pacemaker?

#16

Do you take insulin for diabetes?

#17

Are you currently under medical supervision?

#18

If yes, please explain (medical supervision)

#19

Have you consumed alcohol in the past 24 hours?

#20

Are you currently taking any medication?

#21

If yes, please list (medication)

#22

Are you pregnant?

#23

Is there anything else about your health history that you would like to share?

#24

By signing below, I understand that the training I receive is provided for the basic purpose of personal growth and deeper self-awareness, not medical advice.

#25

Date (Client)

#26

Signature of Practitioner

#27

Date (Practitioner)

#28

Deposit Date (Internal Use Only)

#29

Deposit Amount (Internal Use Only)

#30

Remaining Payment Date (Internal Use Only)

#31

Remaining Payment Amount (Internal Use Only)