First and Last Name
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Emergency Contact
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Current Medications and dosage
Services Requested. Please select all that apply
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Reiki Session
Sound Healing Session
Reiki Facial
Health Information
Are you currently under the care of a physician?
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Do you have any medical conditions, injuries, allergies, sensitivities, or other health concerns that may affect your session?
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Yes
No
If yes, please explain:
Are you sensitive to touch?
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Yes
No
Are you sensitive or allergic to fragrances or essential oils?
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Yes
No
If yes, please explain:
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For Reiki Facial Clients
Have you ever had facial fractures, facial surgery, or broken facial bones?
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Yes
No
If yes, please explain:
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For Sound Healing Clients
Do you currently have any of the following: a pacemaker, metal implants or rods, brain stents, epilepsy or seizure disorders, a heart condition, or are you currently in your first trimester of pregnancy?
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Yes
No
If you answered "yes" to any of the above, please explain below
Important Notice: Certain sound frequencies and vibrations used during Sound Healing sessions may not be recommended for individuals with the conditions listed above. Please consult your physician prior to participation if you have concerns or are unsure whether Sound Healing is appropriate for you.
Consent & Liability Waiver
I understand that Reiki, Sound Healing, and Reiki Facial services are holistic wellness practices intended to support relaxation, stress reduction, and overall well-being. These services are not intended to diagnose, treat, cure, or replace medical or psychological care.I voluntarily choose to participate in these services and accept full responsibility for my health and well-being during and after each session. I understand that I may pause, modify, or end a session at any time and agree to communicate any discomfort or concerns to my practitioner immediately.By signing below, I acknowledge that I have read and understood this form and voluntarily release and hold harmless SPIRITUAL ROOTS YOGA STUDIO LLC and its practitioners from any liability, claims, or damages arising from participation in these services.
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