New Client Form

New Client Form

I appreciate you taking the time to complete my New Client Form. Your input is extremely valuable to me because I am dedicated to providing you with the highest level of service and ensuring you have a great experience.
Studio Hours

Hours by Appointment Only:

Monday- 9:00am-5:00pm

Tuesday- Closed

Wednesday- 10:00am-7:00pm

Thursday- Closed

Friday- 4:00pm-8:00pm

Saturday- 9:00am-12:00pm | 4:30pm-7:00pm |

Sunday- Closed

If you require an appointment outside of our regular hours, I am happy to accommodate your request whenever possible.

These appointments must be scheduled in advance to ensure I can provide you with the best service possible.

Please note that there may be an additional fee for appointments outside of my standard hours,

I appreciate your understanding and flexibility in working with me to find a convenient time that works for both of us.
Personal Information

Please fill out the following personal information for our records
Full Name*

First NameLast Name
Date Of Birth

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Contact Information *

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Personal History

Please provide the following medical history information for our records
Allergies:
Please provide details for each allergy you have to help us ensure your safety and well-being during our services.
Medications being taken:
Please provide details for each medication you are currently taking to help us ensure your safety and well-being during our services.
Previous Injuries and Surgeries:
Please provide any additional information or details related to your previous surgeries or injuries to help us better understand your medical history.
Any current physical limitations:
Please provide any relevant information to help us better understand and accommodate your current limitations.
Goals for Services

Please provide any relevant information to help us better understand and support your goals for our services.
Goals for this Session:
Please share any relevant information or details about your goals for this session to help us tailor our approach and support you effectively.
What specific goals or concerns do you have at this time and want to achieve through wellness services?
Please share any relevant information about your goals and concerns for wellness services to help us support you effectively in achieving your desired outcomes.
Any additional information or preferences we should be aware of:
If there is any additional information, preferences, or specific details you would like us to be aware of, please feel free to share them here. Your input is valuable in ensuring we can accommodate your needs and provide the best possible service. Thank you for letting us know!
Wavier / Release Form

Please read and sign the following waiver/release form before proceeding with our services:
Wavier / Release Form

I, First Name* Last Name* understand and acknowledge that the services provided by Keen Chi Balance may involve certain risks and potential for injury. I hereby release, waive, and discharge Keen Chi Balance and its employees from any liability for any injury, loss, or damage that may result from my participation in the services provided.

I understand that it is my responsibility to inform Keen Chi Balance of any medical conditions, allergies, or other relevant information that may affect my participation in the services. I agree to follow all instructions and guidelines provided by Keen Chi Balance to ensure my safety and well-being during the services.

I have read and understand the terms of this waiver/release form and voluntarily agree to its contents.

Client’s Signature:
Signature* Date*

Please sign and date the form above to acknowledge your understanding and acceptance of the terms outlined.

Thank you,
Keen Chi Balance
Photo Release Form

Please read and sign the following photo release form if you consent to the use of your image in promotional materials.
Photo Release Form

I, First Name Last Name, hereby grant permission to Keen Chi Balance to use my likeness in photographs, videos, and other promotional materials. I understand that these materials may be used in print, online, and other forms of media for the purpose of promoting Keen Chi Balance and its services.

I acknowledge that I will not receive any compensation for the use of my image in these promotional materials. I also understand that I have the right to revoke this permission at any time by notifying Keen Chi Balance in writing.

I agree to release and hold harmless Keen Chi Balance from any liability related to the use of my likeness in promotional materials.

Client's Signature:
Signature Date

Please sign and date the form above to indicate your consent for the use of your image in promotional materials.

Thank you,
Keen Chi Balance
Client Survey

Your feedback is valuable to us and helps us improve our services to better meet your needs. Thank you for taking the time to share your thoughts with us.
How did you hear about us?
(Google, Instagram, Friend) If referred by a friend or family please provide their name. I would love to be able to tank them.
Feedback about us:
Example: Our Website, Customer Service, Experience, Products
Date*

MonthDayYear
Should be Empty:

New Client Form

Personal Information

Personal History

Goals for Services

Wavier / Release Form

Photo Release Form

Client Survey