Client's Name *

First Name

Last Name

Parent/Legal Guardians Name

In the case of a minor under the age of 18 yrs

First Name

Last Name

Client's Phone # *

(###)

###

####

Client's Date of Birth

Please type the date of birth of the person who will be receiving services

MM

DD

YYYY

Client's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

I am interested in the following service(s) *

Reiki

Rife Therapy

Infrared Sauna

Ionic Foot Detoxification

If you chose to receive Reiki, would you like to benefit from the Charmed Far Infrared Mat (complimentary option)?

The radiant heat emitted from the Amethyst & Tourmaline Crystal FIR Mat penetrates up to 6", raising your body temperature, reducing pain/discomfort, increasing metabolism, circulation and relaxation.

Yes

No

Please answer the following questions so that I have a better understanding of your health status and how I may help you: *

Do you suffer from any Disease or Illness?

Yes

No

Check all that apply to you/the client:

Metal Implants

Pacemaker

Seizure Disorder

Heat Sensitivity/Intolerance

Organ transplant recipient

Heart Disease/Condition

Pregnant or Nursing

Please check any categories you have allergies/sensitivities to:

Essential Oils

Incense/Sage

Fragrance

Other

Are you sensitive to touch? *

Yes

No

Do you agree to light, non-invasive touch? *

Yes

No

Have you read the disclaimer and applicable contraindications? *

Yes, I have and I am responsible for booking service

No, I have not but agree to reading it prior to my service

How did you hear about me?

Web search

Friend/Relative

Social Media

Other