SOUND BATH/HEALING INTAKE FORM

FULL NAME
SOUND BATH/HEALING INTAKE FORM
Appointment Date*

DayMonthYear
Date
Email
Please fill in email if you would like to be kept up to date with events and offers.
Phone*
Home Address
Emergency Contact Details*
Name and phone number
Parent/guardian (if client under 16)
Any medical conditions? * It is your responsibility to inform any that may impact a treatment
E.g. heart conditions, pregnancy etc.
Any allergies or sensitivities to fragrances, incense etc.
Have you ever had a sound healing?
Do you have a particular reason for attending?
Is there any additional information you would like to share?
How did you hear about us?
It is my choice to receive A vibrational sound therapy and I understand that the practitioner will be using gentle sound and vibration during the sessions on/around me. I have completed this form to the best of my knowledge. I understand that practitioners do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments or pharmaceuticals. I acknowledge that these sessions are not a substitute for medical examination or diagnosis, and that is recommended I see a primary health care provider for those services.

Cancellations within 48 hours are nonrefundable or transferable.
Please confirm that you have read and agree to the terms above.
Full name
Agreement Date

DayMonthYear
Date
Parent (if client under 16)
Full name
No information about the client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

Any privacy and data retention requests should be sent to tammytait1@gmail.com
Agreement Date

DayMonthYear
Date
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