New Client Registration Form

Name*

First NameMiddle NameLast Name

E-mail*

example@example.com

Gender*

Birth Date*

MonthDayYear

Height (inches)

Weight (Kg)

Contact Number:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In case of emergency...

Emergency Contact:*

First NameLast Name

Relationship*

Contact Number*

Are you taking any medications, currently? (Including any supplements &/or herbal preparations)*

YesNo

If yes, please list it here including dosages

Are you pregnant?*

YesNo

Do you have any allergies?*

YesNo

If yes, please list it here

Current condition(s) and symptom(s) for which treatment requested. (Include all details & symptoms and how long you have had each issue)*

Attach copies of all medical reports, scans or pictures if any.

Treatment Options Requested*

AcupunctureReikiPranic HealingHomeopathy

Patient Photograph

Mode of treatment

{DISCLAIMER}

I am fully aware and understand that the alternative therapy services I wish to receive are those of a holistic nature and are NOT meant to diagnose, treat or cure any disease physical or psychological NOR do they serve as a substitute for professional medical advice, examination, diagnosis or treatment. Alternative therapies are only meant to complement and support the orthodox medical treatments. I will seek the advice of my doctor or other qualified health provider in the case of a medical emergency, medical ailment or in respect of general health questions without delay. I will also continue all medical treatments as prescribed by my physician/doctor and will not alter or interrupt the dosages as prescribed without first consulting a proper medical doctor or physician.

Acu-Health Nature Cure Institute, Coastal Chiropractic, its Management, Employees, Agents, Associates and Therapists whether independent or employed are not medical doctors and do not diagnose, treat or cure any medical condition or disease whether physical or psychological. Their opinions are those of a holistic, complementary and alternative therapist and their opinions, advice, examinations and recommendations do NOT constitute or substitute the advice of a medical doctor/physician.

The body is capable of healing itself and Alternative Therapies are only meant to support this process by correcting the underlying energetic imbalances to restore the body to its natural state of balance, health and well-being. I understand that in some cases the body may experience adverse/cleansing reactions as a result of this process. I also understand that the rate of healing and the results of the healing may vary from person to person and ailment to ailment and hence no guarantees of a successful healing or cure can be given and that it may take several sessions before I notice any benefit. This will also depend on my life style, on-going medication, general health, age and duration of the ailment.

I acknowledge I have given my personal details for the holistic providers use. I understand that my information is protected and I give my consent for the firm to store and use my details. I also understand that if I have been untruthful with my details or have failed to give enough relevant information any treatment could be adversely affected.

I give consent to Acu-Health Nature Cute Institute to contact me for updates on upcoming classes, workshops, events and other email and marketing activities related to the organization. I understand that my contact details will not be shared with any third parties except as required by law.

I have read and understood the foregoing disclaimer and hereby release, hold harmless and indemnify the person/s providing the treatment, Acu-Health Nature Cure Institute, Coastal Chiropractic, its Proprietors, Managers, Employees, Agents, Associates and Therapists whether independent or employed from any claims, litigations and/or liabilities howsoever arising as a result of the services received by me nor will I hold them responsible for any mishaps, adverse health condition/s, reactions or injuries whether physical or psychological or for any loss of income or profits, etc that may occur or result in any form due to my participation in the Healing sessions or use of information therefrom.

For any dispute arising an independent Alternative Dispute Resolution (ADR) mechanism shall be used before commencing any litigation. This independent body would be the Kenya Chapter of the Chartered Institute of Arbitrators, who will be requested to appoint an arbitrator or an arbitral tribunal as the case maybe.

I am completing this form for:*

Disclaimer and Confirmation/Consent

I am fully aware and understand that the alternative therapy services I wish to receive are those of a holistic nature and are NOT meant to diagnose, treat or cure any disease physical or psychological NOR do they serve as a substitute for professional medical advice, examination, diagnosis or treatment. Alternative therapies are only meant to complement and support the orthodox medical treatments. I will seek the advice of my doctor or other qualified healthcare provider in the case of a medical emergency, medical ailment or in respect of any health questions without delay. I will also continue all medical treatments as prescribed by my physician/doctor and will not alter or interrupt the dosages as prescribed without first consulting a proper medical doctor or physician. Acu-Health Nature Cure Institute, Natural Modern Healings Therapies, their Proprietors, Partners, Management, Employees, Agents, Associates and Therapists whether independent or employed are not medical doctors and do not diagnose, treat or cure any medical condition or disease whether physical or psychological. Their opinions are those of a holistic, complementary and alternative therapist and their opinions, advice, examinations and recommendations do NOT constitute or substitute the advice of a medical doctor/physician. The body is capable of healing itself and Alternative Therapies are only meant to support this process by correcting the underlying energetic imbalances to restore the body to its natural state of balance, health and well-being. I understand that in some cases the body may experience adverse/cleansing reactions as a result of this process. I also understand that the rate of healing and the results of the healing may vary from person to person and ailment to ailment and hence no guarantees of a successful healing or cure can be given and that it may take several sessions before I notice any benefit. This will also depend on my life style, on-going medication, general health, age and duration of the ailment. I acknowledge that I have given my personal details for the holistic providers use. I understand that my information is protected and I give my consent for the firms to store and use my details. I also understand that if I have been untruthful with my details or have failed to give enough relevant information any treatment could be adversely affected. I give consent to Acu-Health Nature Cute Institute & Natural Modern Healings Therapies to contact me for updates on upcoming classes, workshops, events and other email and marketing activities related to these organizations. I understand that my contact details will not be shared with any third parties except as required by law. I have read and understood the foregoing disclaimer and hereby release, hold harmless and indemnify the person/s providing the treatment, Acu-Health Nature Cure Institute, Natural Modern Healings Therapies, their Proprietors, Partners, Management, Employees, Agents, Associates and Therapists whether independent or employed from any claims, litigations and/or liabilities howsoever arising as a result of the services received by me or my dependants nor will I hold them responsible for any mishaps, adverse health condition/s, reactions or injuries whether physical or psychological or for any loss of income or profits, etc that may occur or result in any form due to my or my child/parent/spouse/dependant's participation in the Healing sessions or use of information therefrom. For any dispute arising an independent Alternative Dispute Resolution (ADR) mechanism shall be used before commencing any litigation. This independent body would be the Kenya Chapter of the Chartered Institute of Arbitrators, who will be requested to appoint an arbitrator or an arbitral tribunal as the case maybe.*

By submitting this form I confirm that I am over 18yrs old. I have read the above disclaimer statement and I am in Agreement with the same. I hereby give consent to receiving the treatment.By submitting this form I confirm that I am over 18yrs old. I have read the above disclaimer statement and I am in Agreement with the same. I hereby give consent for my child/Parent/Spouse/ Dependant to receiving the treatment.

Signature*