Please Note:
The Client Information Form should be filled out and sent in only after making an appointment with our Customer Service staff.
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* These fields are required.
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Name :
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Address:
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City :
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* State :* |
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Zip/Postal:
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Country:
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Phone:
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(day)*
(evening)
(cell) |
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Email:
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(to receive our e-newsletter and other notices, etc) |
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Date of Birth :
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Emergency Contact:
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Emergency Contact Phone:
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Relationship : |
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Please describe your reason for seeking services at this time:
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Are you currently seeing any other health care practitioner? Yes No
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Please check all that apply:
Psychiatrist Psychologist Therapist
Physician Naturopath Homeopath
Chiropractor Massage Therapist Energy Worker
Other
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| Arthritis Dates: |
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Epilepsy Dates: |
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| Chronic Pain Dates: |
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Multiple Sclerosis Dates: |
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| Diabetes Dates: |
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Ulcers Dates: |
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| Heart/Angina Dates: |
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Headaches Dates: |
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| Cancer Dates: |
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Dermatitis Dates: |
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| Depression Dates: |
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Prostate Problems Dates: |
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| Asthma Dates: |
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Fatigue/Dizziness Dates: |
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| Allergies Dates: |
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Lupus Dates: |
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| Hepatitis Dates: |
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Vision Problems Dates: |
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Please use the space below to give details of the above, or if your medical condition is not listed.
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I, understand that session fees are as follows:
- Office sessions -- $ 95 or $80 depending on who my appt is with
Introductory Session recommended for new clients is $95.00
- Group sessions -- $ 75 or $60 (per person) depending on who my
appt is with
- Phone sessions -- $ 90 or $75 depending on who my appt is with
(Animal phone sessions: $40.00)
- Qi~ssage sessions -- $45 or $80 depending on length of appointment
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I understand that I am responsible for payment of fees at the time services are provided, unless otherwise arranged with Spring Forest Qigong ® .
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Signature: Date:
By clicking this box and entering your name into the box above, you are digitally signing this form and will be treated the same as if a signature was written on paper. |
* Spring Forest Qigong® is a Complementary and Alternative Health Care Provider. Please do not discontinue or alter medical treatment without first obtaining appropriate medical advice.
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Please Note:
The Client Information Form should be filled out and sent in only after you have made an appointment with our Customer Service staff.
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"A healer in every family and a world without pain."