Confidential Client Case History and Intake Form

Confidential Client Case History and Intake Form
Please note: If you already completed these forms prior to your first session, then it is not necessary to complete these forms again.

NOTICE:

Information collected via forms will be administered and transmitted initially according to Jotform Inc.'s privacy and security policies and protocols. Wendy Dingwall and The Vegan Shaman brand will access this information and will hold it in the strictest confidence with reasonable due diligence and best practices for a practitioner.

You are hereby advised to avoid sharing any information for which you feel you are putting yourself at risk. Using these digital, electronic, and internet-based means of information sharing and transmission are accordingly your choice and with your understanding of the means by which this information is captured and shared.
Have you read and do you understand the information contained within the notice above?
Name
Address

Address

Street Address Line 2

CityState / Province

Postal Code
Phone
Format: (000) 000-0000.
Email Address
example@example.com
Would you like to receive updates via email?
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Referred by:

What is(are) your primary concern(s)?
What is the severity of your primary concern(s):
Rate from 1 (hardly notice symptoms) to 10 (symptoms are unbearable)
Medication(s), Remedies, and/or Supplement(s) *and* Reason(s) for taking:
Significant Accidents and/or Injuries:

Client Participation Consent Form
I, {name}, consent to treatment for myself (or my minor child), and I understand that services provided by the practitioner Wendy Dingwall are intended to enhance relaxation and increase communication within my body.

I understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan.

I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided.

I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I give the practitioner consent to use my case history and results without using my name. I understand that only the practitioner, Wendy Dingwall, will have access to my information on record only to enhance my healing.

In the event that you need to cancel or reschedule your appointment, we would appreciate at least a 3-hour notice by phone call; that phone number is: (941) 529-1271. We do reserve the right and option to deny rescheduling if cancellations are excessive.

We do not have a refund policy; however, you are invited to reschedule your session for a future appointment.

I understand that by providing this informed consent I am assuming full responsibility for my experience, and I hold harmless both the practitioner, Wendy Dingwall, and the facility/location where the services are provided.

I agree to these terms and conditions set out by this consent form and certify that the above information is true and correct. I agree to pay for any and all sessions for which I have requested.
Have you read and do you understand the intention of your consent to be given as presented above?
Date of Your Consent:
Do you affirm that you agree to the terms and conditions set out by this consent form and certify that the above information is true and correct.
Please type your formal name here to represent your electronic signature.

Thank you again for providing your information—and now also your consent.

NOTICE:

After you click the [Submit] button below to transmit this information directly to Wendy, next you will be invited to Wendy's scheduling system to request a day and time for your upcoming session appointment.

Here we go...
Should be Empty: