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CLIENT INFORMATION - CONFIDENTIAL Date: ____________________ Birthday _____________________
Age :__________ Address: _______________________________________________________________ City, State, Zip: _________________________________________________________ Phone Number: __________________________________________________________ Fax No. (optional): ________________ Email (optional): __________________________Please add email address to monthly newsletter and specials? ____________________ Date: _____________________________Your Birthday: ________________________ Session for You or Your Pet? _______ Pet's Name & Birthday_____________________ Session for In-Person or Long-Distance? _____________________________________ Referred by: ____________________________________________________________ Reason for session: _______________________________________________________ Have you had energy healing before? ___ What Method? How Often? ______________ No medical claims, promises or guarantees are made as to the effect or outcome of this treatment approach. I am neither diagnosing nor treating specific health challenges. You are solely responsible for seeing to and continuing with your own medical treatment and care. This session should be viewed as a complement to, rather than a replacement for, traditional medical approaches. Each person is encouraged to be responsible in the use and choice of professional healing assistance, as needed. I have read and understood the above disclaimer. I hereby assume
all risk of reaction or injury from this session, or any future sessions,
and waive any right of recovery from, or to bring suit against the
practitioner, Nancy Dutton, or related associates. By signing this
document, I verify I have read, understand and consent to this waiver: |
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| Signature (Guardian's Signature, if a Minor):_____________________________ | |
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Print Name: ________________________ |
Date: __________________ |