Client Registration Form - Reiki

Name

First

Last

Name you taking

Email

Emergency Contact Name

First

Last

Emergency Contact's Phone Number

Do you have any diagnosed medical conditions?

Please list details. If none, mark it as N/A.

Are you taking any medications?

Please list what including supplements.

Have you had any recent surgeries or injuries?

Do you have any of the following?

What brings you to this session?

Is there a specific issue or area you’d like support with?

Is there anything else I should be aware of regarding your health?

Disclaimer

I agree and consent.

I understand that Reiki is a complementary therapy intended to support relaxation and wellbeing. It is not a substitute for medical diagnosis or treatment. I confirm that I have provided accurate health information and will inform the practitioner of any changes. I consent to receive Reiki treatment. I understand I can stop the session at any time. I give permission for hands-on treatment (with the option to request hands-off).

Client Registration Form – Reiki