CLIENT INFORMATION

Name:  __________________________________    Date:  _____________________________

E-Mail:  _______________________________________________________________________ 

Date of Birth:  _________________  Place of Birth:  __________________________________

Address:  _____________________________________________________________________

City:  ________________________________ State:  _________  Zip Code:  ______________

Home Phone:  _________________________  Cell Phone:  _____________________________

Occupation:  ___________________________________________________________________

How did you hear about us? _______________________________________________________

Person to contact in case of an emergency/phone number:  _____________________________

Please describe any concerns and your objectives in seeking

wellness services here:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Informed Consent

I understand that the attending practitioners/massage therapists are not allopathic doctors (MDs) and do not portray themselves to be but are providing Biofeedback, Massage and Wellness Services.  I understand that the services provided identify energetic imbalances.  Procedures utilized include stress reduction protocols, nutritional wellness consultation and biofeedback.  I fully understand that the attending practitioners do not offer allopathic drugs, surgery, chemical stimulants, or any other conventional treatments.  In addition, we do not diagnose, treat, heal, or otherwise prescribe for my disease, illness conditions or perform any act that would constitute the practice of medicine for which a license is required.  I have solicited the attending practitioners' services in good faith, exercising my free will and following the dictates of my own conscience which allows me to select what I understand is most beneficial to my health.  I am fully aware and release the practitioner to do Biofeedback, wellness consultation and other stress reduction protocols.  By signing below I acknowledge that I have read and understand all parts of this waiver, that I had the opportunity to ask any questions with regard to the described procedures, and that I hereby affirm: I am not here for medical diagnostic or treatment procedures and I am here on this and any subsequent visit solely on my own behalf.

____________________________________                      __________________________

Signature of Client                                                   Date