Biofield Tuning Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please tell us who referred you so we can thank them:
What are your goals for our sessions together?
Are there any questions or concerns that you feel we should address prior to your session?
Please mark any of the following contraindications that may apply to you:
Pregnancy or planning to become pregnant
Cancer or terminal illness
Heart condition/pacemaker
Concussion or head injury in the last 6 months
Please mark any of the following additional health information that may be helpfulfor your practitioner to know:
Recent broken bones
Obesity
Epilepsy
Currently taking medications
Other
If you marked any of the above, please provide more information:
*Signature of Client (or Parent or Guardian if Under 18) By filling in my electronic signature, 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 of Client (or Parent or Guardian if Under 18) By filling in my electronic signature, I agree that I have provided my information to the best of my knowledge, including pertinent health information.
Submit
Should be Empty: