"Creating Change" Health Waiver
Please take a minute to fill in the following information
First Name
Last Name
Email
Phone Number
Date
Birthdate and Place of Birth if interested in Biofeedback session
Address
Phone Number
Do you have any neurological, ocular or medical issues?
Yes
No
Briefly describe any Physical or Emotional issues you are having.
What would you like help with today?
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I, the undersigned, acknowledge that I understand and agree to the following: I agree to pay you for your services, in full, on or prior to the date of each session. I agree to give you 24 hours notice for all cancellations or changes of scheduled
I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of my sessions.
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