Pet Consultation

Schedule A Pet/Animal Consultation
Owner Information
Owner's Name*

First NameLast Name
Owner's Email*
example@example.com
Owner's Phone Number*
Please enter a valid phone number.
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Seeking Shalom - Emotional Healing?*

FacebookGeneral web search found this websiteReferred by someone (please enter their name in the Other section below)Other

Services
Bach Flower Consultations
- $50* Initial Consultation includes personalized remedy bottle
- $25*/half our Follow-Up Consultations include personalized remedy bottle
LimbicArc
- $100 monthly subscription
- Do a Spark Scan as often as once every 24 hours
- Run up to 5 infoboosts simultaneously, selecting from over 800 ingredients
- Add up to 8 friends and family for only $10/month each
LimbicArc + CERT (Cook's Emotional Release Technique)
- $150 monthly subscription
- Do a Spark Scan as often as once every 24 hours
- Run up to 5 infoboosts + 1 CERT infoboost simultaneously, selecting from over 800 ingredients
- Add up to 8 friends and family for only $10/month each (includes CERT for free)
* Payment in full is required via PayPal or cash prior to appointment.
What service or services are you seeking? (Select all that apply.)*

Bach Flower ConsultationLimbicArcLimbicArc + CERTOther
Please give the top 3 reasons for your visit, in order of priority.*
Do you have any questions you would like addressed at your appointment?*

Nutrition
What kind of water does your pet/animal drink?*

Municipal water supplyWell waterSpring waterBottled waterOther
What foods do you feed your pet/animal?*

Supplements / Medications
Is your pet/animal on any supplements? If so, which supplements, how much, how often, and what for?*
Is your pet/animal on any medications (OTC or recommended/prescribed by a vet)? If so, which medications, how much, how often, and what for?*
Has your pet/animal received any vaccinations? If so, which vaccines and when? *

Medical History
Has your pet/animal had any surgeries? If so, what surgery and when?*
Has your pet/animal been given any diagnoses by a vet? If so, what diagnoses and when?*

Naturopathic History
Have you ever been in consultation with a Naturopath or Naturopathic vet about your pet/animal? If so, why and how long ago? What was suggested? Did you experience a good outcome with your pet/animal? What did you like about it? What was not as successful for your pet/animal? *

Scheduling My Appointment

Please select your top 3 choices for your appointment time.
Appointment - Choice #1*
Appointment - Choice #2*
Appointment - Choice #3*

Signature
By signing and dating below, I certify that the information I have provided in this application is accurate. I also understand that I am responsible to make payment in full prior to services provided. I also understand that I am here to learn about natural health practices, that I will be offered information about whole food, supplements, herbs, homeopathy, flower essences, enzymes and more, as a guide to general good health. I acknowledge that this is a personal ministry offering spiritual counseling and personal empowerment. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on holistic wellness matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment, or prescribing of cures for disease or medical conditions.*

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Schedule A Pet/Animal Consultation