Consent Form - Angelic Wings of Reiki

Client Intake and Consent Form for Reiki Treatments

Name *

Date *

Home Phone

Mobile *

Preferred contact method *

Home Phone
Mobile
Email

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Gender *

Female
Male
Prefer no to say

Age *

Date of Birth *//

Occupation

Women Only: Pregnant?

If "Yes" Due Date?//

Family & Home Status *

Single
Married
Partner
Children

Emergency Contact Name *

Emergency Contact Phone *

GP Name (For Emergency Only) *

GP Phone Number *

Please list any special health issues or requirements you would like me to know about (include health restrictions, allergies or other health concerns.

Are there any other issues that may affect your sessions with me?

Have you had a Reiki treatment before? *

If "Yes" When (Approx)

Number of treatments (roughly)

Why you had Reiki treatments (What For?)

What do you want to get from your Reiki treatments?

If you selected "Other" please mention the reasons.

What specific physical issues would you like to improve or heal?

What specific emotional issues would you like to improve or heal?

Are you currently seeing other health practitioners?

What else are you doing to support your health and personal well-being?

Might you have any difficulty lying on your back (on a padded surface with support under your knees if required) for the entire treatment (1 hour)? *

Do you give permission for me to use my hands directly on your body in a non-invasive way? *

Would you prefer to have your session, or part of your sessions, in a chair that keeps your body upright? *

Do you have any additional comments or questions before we begin your session? Feel free to write them here or speak to me about them before we begin the Reiki treatment.

How did you hear about me?

Are you interested in learning more about Reiki?

Name *

First

Last

Date *

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the government and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Angelic Wings Of Reiki has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Angelic Wings Of Reiki can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.
I voluntarily seek services provided by Angelic Wings of Reiki and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
- I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
- I have not travelled internationally within the last 14 days.
- I have not travelled to a highly impacted area within the United Kingdom in the last 14 days.
- I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
- I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by government or local public health authorities.
- I am following all government recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

I hereby release and agree not to hold Usha Kaur responsible for, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the centre, or that may otherwise arise in any way in connection with any services received from Angelic Wings Of Reiki. I understand that this release discharges Angelic Wings Of Reiki from any liability or claim that I, my heirs, or any personal representatives may have against the centre with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Angelic Wings Of Reiki . This liability waiver and release extends to the centre together with all owners, partners, and employees.

Signature

Client Intake and Consent Form for Reiki Treatments

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