Tuning Fork Intake Form
Today's Date
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First / Last Name
Email Address
Address
Phone Number
Date of Birth
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Which area of life are you wanting healing for?
Clear choice
Physical
Emotional
Clear the Mind
Balance
Relieve Stress
Relieve Tension
All of the Above
Other
If Other, please list all that apply.
I understand that by signing this form I give the Practitioner permission to provide the requested service within the scope of her License or Certification.
I understand that servides received by me from the Practitioner are for the purpose of relaxation, stress reduction, pain reduction, detoxification and energy balancing. I further understand that a tuning fork session should not be considered as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for mental or physical ailments of which I am aware.
I understand the Practitioner is not qualified to perform skeletal adjustments or diagnose, and anything said during the session should not be construed as such.
I acknowledge that I have read and understand this form. I agree to allow the Practitioner to help me learn to heal myself using the natural healing techniques and modalities available to me through this Practitioner.
Signature
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Verification
SUBMIT FORM
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