Client Intake Form 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 Email * 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 * (###) ### #### Emergency Contact Relationship * Service is for: * Myself Child I am interested in the following service(s): Reiki Infrared Sauna Rife Therapy PEMF Therapy Clients receiving Reiki can also benefit from the Charmed Far Infrared Mat ~ * 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. Do you agree to this complimentary service? Yes No Not Applicable Please answer the following questions so that I have a better understanding of your health status: Do you suffer from any Disease or Illness? Yes No If "Yes" please describe: Check all that apply to you/the client: Metal Implants Pacemaker Seizure Disorder Heat Sensitivity/Intolerance Are you pregnant or plan to become pregnant? * Yes No Not Applicable Do you have any allergies? * Yes No If "Yes" please describe: If applicable, please check the following: I am sensitive/allergic to: Essential Oils Fragrance Incense Other If you checked "other" please describe: Are you sensitive to touch? * Yes No If "Yes" where are you sensitive? Do you agree to light, non-invasive touch? * Yes No Please describe any areas of concern: Have you read the disclaimer and adverse reaction information? * 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 Thank you for taking the time to complete this form. Your information is safe and confidential.I look forward to helping you reach your wellness goals.
