Biofield Tuning Client Intake Form

Biofield Tuning Client Intake Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Who can I thank for the referral?
What are your goals for our session together?*
Are there any questions or concerns that you feel we should address prior to your session?*
pregnant or planning on becoming pregnantCancer or terminal illnessHeart condition / pacemakerConcussion in the last 6 months
recent broken bonesepilepsycurrently taking medicationsOther
If you selected any of the above, please provide more information below:
I grant my practitioner permission to use hands-on touch and the application of weighted forks and a crystal to my body. I am aware that I may verbally revoke this permission at any time before, during, or after a session.
Signature*
I have provided my information to the best of my knowledge, including pertinent health information.
Signature*
Should be Empty: