Energy Arts Client Intake Form

Energy Arts Client Intake Form

Your journey begins here — help us understand your needs by completing this form.
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Are you currently under the care of a physician?

YesNo
If yes, physician’s name:
Current Medications and dosage
Are you sensitive to perfumes or fragrances?

YesNo
Are you sensitive to touch?

YesNo
Do you have a particular area of concern?
Have you ever had an Energy Healing session before?

YesNo
If yes, when was your last session?
What are your goals for receiving Energy Healing?
How did you hear about BodyIgnite, LLC?
By signing below, you confirm that you’ve read the information, answered honestly, and agree to receive services.*

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