Initial Consult Form - BodyConnect Healing

Name*

First Name Last Name

Date of Birth*

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Address / Country:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile number (with country code):*

What’sApp/Viber #:

Skype user name:

Email*

Occupation:*

How did you hear about us?*

If referred, please let us know whom to thank!

Please list your health concerns in order of importance:*

How long have you had it for?

Please specify known allergies/sensitivities?*

If you have any life threatening allergies (e.g. anaphylaxis, medication), please list here:*

If you have pets please list here:*

Please list any past injuries/surgeries?*

Do you or have you smoke(d)? Y N*

How long?

When did you quit?

Are you under emotional or physical stress? Please describe.

Do you have trouble sleeping? Please describe.

Medication you are currently taking:*

Name/Brand/Type	For what condition?	How long?

Natural health products you are currently taking:*

Product/Brand/Dose	For what condition?	How long?

Do you have a pacemaker? Y N

Medical issues /concerns you haven’t informed us of? Y N*

Please specify:*

Waiver and Consent

I understand that the session I receive is a complementary alternative energy based treatment that can assist my body and its natural ability to heal. I fully acknowledge and understand that this may accomplished through the use of contact when done in person and no contact when done from afar.

I understand that this complementary session is not intended to replace any currently prescribed medical treatments as ordered by my physicians or any other medical care that I may be advised to seek by them.

I understand that my BodyConnect Practitioner will neither diagnose nor prescribe for any condition that I might have nor does she make any specific claims regarding results from the sessions I receive.

I understand that she is not licensed to practice conventional medicine.

I understand a small percentage of people may experience tiredness or headache developing after the treatment and lasting usually no longer than 24 hours. If more severe reaction occurs it is my, the client’s, duty to contact the practitioner and seek medical treatment if needed. It is uncommon, but on some occasions my symptoms may be temporarily aggravated as a part of my body's healing process or if more sessions are needed to clear a particular concern.

I understand that all client information and records are treated in a confidential manner. My experiences during these sessions are confidential and subject to the usual exceptions governed by State or Federal laws and regulations.

I understand that there is a 24-hour cancellation policy and if I fail to cancel 24 hours prior to my appointment, I will be charged the full amount.

I declare that all the information I have given is correct and I have answered the questions to the best of my knowledge. I have disclosed all past and current test results, diagnoses and medical treatments that I have received.

To read Privacy Policy click here.
To read Terms and Conditions, click here

* By electronically entering today's date, I consent to the Waiver, Privacy Policy and I accept the Terms and Conditions.

Today's Date:*

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