Registration Form – Healing Touch and Wellness Centre

Name *

First

Last

Email *

Phone Number *

D.O.B *

Address *

Occupation

Last Visit to a Doctor and Reason

Current or past Health Problems or Concerns

Are you on Medication? *

History of Epilepsy/Seizures

Do you wear any prostheses( artificial limbs, hearing aid etc.) *

Do you have any Allergies?

How is your Blood Pressure?

Are you pregnant? If yes, when are you due?

Energy work Consent and Release Statement *

I accept the terms of service below

I understand that the Reiki/Energy/Body Work session given involves a natural hands-on method of energy balancing for the purpose of pain management, stress reduction, and relaxation. I understand very clearly that these treatments are not intended as a substitute for medical or psychological care. I understand that holistic health practitioners do not diagnose conditions, nor do they prescribe medicines, nor interfere with the treatment of a licensed medical professional. Also I agree to pay the fee for all required sessions as per the price list or as mentioned. I acknowledge that I have read this form and understand the procedures that practitioner will perform. I consent to receive energy and body work and intend to apply this consent to all of my future energy/body work (Reflexology, Reiki, Aromatherapy, Thai Yoga, Chakra Massage & Alignment, Healing Touch Therapy, Hot Stone Massage, Crystal Healing etc.) sessions. I understand that the practitioner will be placing hands & working on me in a prescribed format during the Energy/Reiki/Body Work/Combined Therapy sessions.

Type your name to accept the Energy work Consent and Release Statement *