Acupuncture Initial Intake

Acupuncture Sound Bath

Tabernacle W11 Jacina and Dr. Gene
Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Cardiac pacemaker or electronic implanted devices?*

YesNo
Epilepsy or seizure disorder?*

YesNo
Women only: Are you currently pregnant ? Hit 'No' if you are a guy!*

YesNo
I have been diagnosed with a mental health condition*

YesNoOther
I am not aware of any medical conditions that would make me unsuitable for acupuncture or sound bath*

Nothing to worry about hereI need to mention a few things.....(e.g. tinnitus or sound sensitive epilepsy)?
Any current serious medical conditions we should be aware of? Blood born infectious diseases e.g. Hepatitis / HIV / Blood clotting disorder, currently undergoing cancer treatment etc.
www.jacina.com
Please tick all that apply

I want to have acupunctureI am in good healthI am ok to have sound therapyI am ok for you to contact me about future eventsI agree to you videoing and photographing this for your promotions I permit you to use my image for your promotion of future eventsI am over 18 year old
I understand that this experience is free and is being filmed and recorded for our marketing purposes. I agree to allow Jacina Coyne and Genevieve Marais to use photography & video of me and the group to promote their future sound bath events.

I promise to have answered all questions honestly and believe there is nothing stopping me enjoying the acupuncture and sound bath energy medicine experience.
Participant Signature *

Clear
Todays Date*

MonthDay Year
Date
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Acupuncture Sound Bath