Dream City Healing Co New Client Form

Introduction

Please complete this New Client form and we will connect you with a practitioner.
Date

MonthDayYear
Date
Full Name*

First NameLast Name
Pronouns*
E-mail*
example@example.com
Phone Number*
Current Residence*

Street Address

Street Address Line 2

CityState/Province

Postal/ Zip Code
Date of Birth*

DayMonthYear
What is your best form of contact?*
What goals do you have/ Why are you seeking treatment?*
Your Medical History

Please provide us with a detailed health history so that we can work to protect you and serve you throughout all of our sessions.

Your Exercise History:*

	Currently 3x/week or more	Currently 1x/week or more	Less than 1x/week	In The Past	Never
Studio-based Yoga Practice
Home-based Yoga Practice
Physical Training with Weights
Walking/Jogging
Climbing/Above-The-Ground Practice
Swimming/Water-based Practice
Bicycling
Meditation Practice
Other: (please specify)

Other - Please Specify:
Are you taking any prescribed medications or dietary supplementation?*

YesNo
Please provide details
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?*

YesNo
Please provide details
Do you have any injuries, tension, or soreness in any area?*

YesNo
Please provide details
Do you have any orthopedic problems (back, knees, etc), or stiff/swollen joints?*

YesNo
Please provide details
Has you doctor ever said your blood pressure was too high or too low, or do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?*

YesNo
Please provide details
Do you have diabetes or has your doctor ever told you that your cholesterol was too high?*

YesNo
Please provide details
Do you ever have problems sleeping?*

YesNo
Are you pregnant or post-partum (< 6 weeks)?*

YesNo
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?*

YesNo
Please provide details
Our Waiver

Please carefully read, confirm, and sign the liability waiver below. You will be connected to a healing artist (titled "The Practitioner") who will guide you deeper into your journey based on your goals and medical history.
I, First Name*   Last Name*, understand that the services I receive from [The Practitioner] are provided with the complete intention of wellness, and it is my responsibility as the client to communicate any time a practice seems uncomfortable or detrimental to my well-being. At every visit, I will provide the practitioner with all relevant information regarding my current state of health, and inform them with complete disclosure and honesty of any injury or condition that may be affected by the treatment or bodywork received. Some forms of therapy, such as acupuncture, will involve the use of sterile, single-use needles placed in the skin, as well as electrical stimulation, moxibustion (herbal stimulants), cupping, and other techniques involving manual manipulation of the body. I agree to take full responsibility for my health, and for all results of the treatments that I receive from [The Practitioner], favorable or adverse. I understand that there is no guarantee regarding the effect of the treatment provided, and that I am free to cease the treatment at any point in time. Alternative forms of therapy are not a substitute for western medical treatment, and I will see a physician, chiropractor, or other qualified specialist if an acute illness or injury were to arise.
      Confirmed   Denied*

I will not make any claims against [The Practitioner], Dream City Healing Co, and/or any of its representatives or heirs, or hold [The Practitioner], Dream City Healing Co, and/or any of its representatives or heirs liable for personal injury, property damage/loss, wrongful death, or other conditions, whether I perceive them to be caused by negligence, or otherwise.
        Confirmed   Denied*

In summary, I acknowledge that the practice of holistic wellness begins within myself, and is fed by all areas of my life. I am in personal control of all aspects of my wellness, from the food that I eat to the activities in which I engage myself. I recognize that [The Practitioner], and the treatment that they provide, is a tool with which I may facilitate that wellness, but I take full responsibility for the realization of any and all of my health and wellness goals.
       Confirmed   Denied*

As Dream City Healing Co promotes clear and open communication, [The Practitioner] adheres to a 24 hour cancellation policy. Appointments cancelled with less than 24 hours’ notice will be charged a $50 cancellation fee. Late appointments and appointment no-shows will be charged for the full price of the scheduled service. In the case that [The Practitioner] has an emergency or becomes ill and needs to cancel my appointment on the same day that it is scheduled, they will find a replacement practitioner for my treatment if at all possible, or reschedule my appointment for another time at no penalty to them.
      Confirmed   Denied*

On this Date*  I, First Name*   Last Name*, have carefully read and comprehend all above-stated policy and release of liability, and am in agreement with the terms of this contract.
       Confirmed   Denied*
Signature

Clear
Should be Empty:

Introduction

Your Medical History

Our Waiver