Today's Date
Full Name of Patient/Client to be treated
Date of Birth
Full Mailing Address
Occupation
Phone Number
Referred by:
Have you had massage/Reiki before? How long since last treatemnt?
What is your reason for choosing massage/Reiki? What results are you hoping to get from this treatment?
Check all that apply you:
Any other conditions, syndroms, recent accidents, any thing else pertinent to your health status?
User Agreement
Minor Child/Legal Guardian Consent (Only check if for a minor child)
By printing my name below, I state that all the information I submit is true. If signing for a minor child, state "your name for name of child" Name and Date: