Reiki Client Registration Form

Reiki Client Information

Please fill in the form below
Name:*

First NameMiddle NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number:

Area CodePhone Number
Cell Phone Number:*

Area CodePhone Number
E-mail:*
Birth Date

MonthDayYear
Previous Reiki experience

YesNo
How did you hear of us?

internet search for reikiinternet search for Susan Grace Wisniewskisocial mediareiki.orgfrom a friend
Have you been vaccinated for Covid-19?

YesNo
Occupation:
In case of Emergency
Contact:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Relationship:*
List treatments or medications client is currently receiving and for how long?*
Comments and history (physical problems, current or past injuries, life transitions):What you would like the reiki treatment to focus on.*
Current outlook on life:*
Life qualities you wish you had more of in your life:*
I understand and agree to authorize Susan Grace Wisniewski to treat me with Reiki techniques and to retain the information provided above.
Signature*

Clear
Date:

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

In case of Emergency