Client Intake Form

Client Intake Form

Please fill in all information and e-sign
Name
Date of Birth

MonthDayYear
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Details
Contact Person Name
Primary Phone Number
Secondary Phone Number
Medical History
Are you pregnant?

NoYes
Do you have epilepsy?

NoYes
Do you have any known allergies? If yes, then please specify below.
What are your current, most concerning, symptoms? Please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.? Please specify below.
Acknowledgment, Authorization and Waiver
Client Understanding

I have read and have asked questions about the programs that I will be receiving. By signing this form below, I agree to the procedures that will be carried out in my presence or out of my physical presence.I understand that Energy and Allergies(DBA Allergies BeGone), Steve F. Pulvermacher, makes no guarantee in success of the treatment(s), but will use his best knowledge and ability to try to achieve the highest and efficacious results.Except in the case of gross negligence or malpractice, I, the Client, or my representative(s) agree to fully release and hold harmless, Energy and Allergies (DBA Allergies BeGone), Steve F. Pulvermacher, from and against any and all claims or liability of any kind, including catastrophic nature, in connection with all procedures.I release Energy and Allergies (DBA Allergies BeGone), Steve F. Pulvermacher, from any liability for loss, damage or injury to my person from my consent of programs.I understand that my consent extends to any future programs from Energy and Allergies(DBA Allergies BeGone) with Steve F. Pulvermacher.I acknowledge that all information I provided in this form is true and accurate.
Practioner's Affirmation

I Steve F. Pulvermacher, in the course of my procedures carried out on Clients, make no claims to diagnose, cure, or treat any diseases or medical conditions.

I, Steve F. Pulvermacher, conduct my procedures with the technique of "Muscle Testing", to determine allergies that a Client may have.

I, Steve F. Pulvermacher, may use cold laser/soft light therapy to balance Clients.

In the case of a non-allergy symptom, the cold laser/soft light therapy will not be applicable or successful.
Client/Parent/Guardian Signature

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Date Signed

MonthDayYear
Should be Empty:

Client Intake Form

Emergency Contact Details

Medical History

Acknowledgment, Authorization and Waiver

Practioner's Affirmation