Energy Therapy Client Intake Form
New Facial client information
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Email *
Name *
Date *
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Address *
Cell Phone (we text appointment reminders) *
Emergency Contact *
Can we use your email for newsletter and promotions?
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Birthday (we send birthday coupons) *
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DD
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How did you hear about us? *
Is this your first energy therapy treatment?
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If No, When was your last session?
Number of previous sessions?
Are you currently under a physician's care? *
Are you Pregnant? *
Are currently under any medication? (Please list) *
Do you have a particular area of concern?
Are you sensitive to perfumes and fragrances?
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Area you sensitive to touch?
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What is your stress level on a scale of 1-5?
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I understand that this energy treatment is a simple, gentle technique that is used for stress reduction and relaxation. I understand that the practitioner does not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances,  nor interfere with the treatment of a licensed medical professional. I understand that this energy treatment does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that this energy therapy may compliment any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. *
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Signature of Client (please type your name) *
Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.
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