Reiki Healing Session
Appointment Registration Form
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First Name *
Last Name *
Email *
Phone Number *
Date of Birth *
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Occupation *
Delivery Address *
Emergency Contact Details
(Name, Relationship, Telephone)
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Describe any Past Medical History 
(Depression, Illness, Surgeries etc.):
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Indicate any other Healthcare Professionals you are currently seeing:
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What are your goals for this Reiki Healing Session?
 *
Please indicate your level of Health Stress
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Please indicate your level of Relationship Stress
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Please indicate your level of Family Stress
 *
Please indicate your level of Work Stress
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Please indicate your level of Financial Stress
 *
Date of Appointment  *
MM
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DD
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Time of Appointment  *
Mode of Session
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How did you hear about FlowersandChar? *
Thank you for registering your appointment with FlowersandChar. 

While we apply our best efforts to protect your personal information once received, no data transmission over the Internet can be guaranteed as 100% secure and you agree to transmit all such information at your own risk. 

You understand that Reiki Healing Sessions provided at FlowersandChar is a complementary health service intended to improve energetic balance and is not a substitute for medical treatment or medications. There is also no diagnosis of illness or disease nor prescription of medications. 

You understand that participation in any session is always voluntary and that you may choose to end your participation at any time. You understand that information exchanged during any session is educational in nature and is to be used at your own discretion.  

You understand that by providing this informed consent you are assuming full responsibility for the session and hold harmless Reiki Practitioner, health clinic, and facility/location where the session is provided. 

Please give 24 hours notice if you are unable to make it to your appointment. In the event of a late cancellation or non-attendance, the full fee will apply. 

If you have any questions about these matters, please feel free to email us at flowersandchar@gmail.com. 

By submitting this form, you acknowledge that you have read, understood and agree with this document and wish to proceed with a Reiki Healing Session with FlowersandChar.
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