Holistic Pulsing - Client Intake Form

This form must be completed and signed before receiving any treatment.

General and Medical Information

Name

DOB

Date

Address

Email

example@example.com

Phone

Occupation

How did you hear about me?

Have you experienced any complementary therapy treatments?

YesNo

Please specify

Are you currently under a physician's or other specialist's care?

YesNo

Please provide Physician's/Specialist's name/contact details

Are you pregnant, if so, how many weeks?

Are you taking medications/supplements?

YesNo

Please specify

Please provide details of any accidents, illnesses, operations & injuries. (Type, age etc)

Holistic Pulsing attends to the whole body, head to toe to fingertips (with the exception of genitalia If you have any concerns, please discuss them prior to the commencement of your treatment.

I understand that the bodywork I receive is provided for the basic purpose of relaxation, transformation, and relief of muscular & emotional tension. When I experience any pain or discomfort during the session, if necessary, I will inform the practitioner so that the pressure and/or pulses may be adjusted to my level of comfort. I further understand that this bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the session given should be construed as such. Holistic Pulsing should not be performed under certain medical conditions, as such, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile prior to the session and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that the practitioner reserves the right to refuse to perform Holistic Pulsing on anyone whom they deem to have a condition for which this is contraindicated.

IN CONSIDERATION of my payment for participating in the activity provided by Dragon Energy Healing (and the extent that the same may be precluded by statute) I ACKNOWLEDGE AND AGREE TO RELEASE AND INDEMNIFY the Practitioner as follows:

1. I participate in the activity at my own risk and responsibility.

2.I release, indemnify and hold harmless the practitioner from and against all actions or claims that may be made by me or on my behalf by other parties in respect of or occurring from an injury, loss, damage, or death caused to me or my property whether from negligence, breach of contract or in any way whatsoever or any liability that results from the breach of an express or applied warrant that the treatment will be rendered with responsible care or skill.

3. If I am injured or my property damaged, there will bring no claim, legal or otherwise, against the practitioner in respect of the injury or death.

By signing this document, I acknowledge that I have read and understood all content and know that it affects my legal rights.

Client Signature

Date