Waiver
Please take a minute to fill in the following info prior to your appointment.
First Name
Last Name
Date of Birth
Email
Phone Number
Address (with Postal Code, City, Province, etc.):
Do you have a doctor’s permit to participate in physical activities?
Yes
No
Not Needed
Please specify any medications or supplements you're taking:
Please specify any medical conditions you have, if applicable:
Do you or have you ever suffered from seizures?
Are you receiving other alternative treatments?
Yes
No
Emergency Contact Info (First & Last name, Number, & Relationship to you)
Are you okay with being touched *appropriately* during your session? (Reiki only)
Yes
No
Did someone refer you? If yes, please specify who (First & Last name, & Number):
I agree to the terms & conditions
Your Signature
*
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