Spring Forest Qigong - Client Information Form

Please Note:
The Client Information Form should be filled out and sent in only if you are about to make an appointment or have already made an appointment.

* These fields are required.

Name:

Address:

City:

* State: *

Zip/Postal:

Country:

Phone:

(day) *

(evening)

(cell)

Email:

Date of birth:

Emergency Contact:

Emergency Contact Phone:

Relationship:

Please describe your reason for seeking services at this time:

Are you currently seeing any other health care practitioner? Yes No

Please check all that apply:

Psychiatrist Physician Chiropractor Other	Psychologist Naturopath Massage Therapist	Therapist Homeopath Energy Worker

Arthritis Dates:		Epilepsy Dates:
Chronic Pain Dates:		Multiple Sclerosis Dates:
Diabetes Dates:		Ulcers Dates:
Heart/Angina Dates:		Headaches Dates:
Cancer Dates:		Dermatits Dates:
Depression Dates:		Prostate Problems Dates:
Asthma Dates:		Fatigue/Dizziness Dates:
Allergies Dates:		Lupus Dates:
Hepatitis Dates:		Vision Problems Dates:

Please use the space below to give details of the above, or if your medical condition is not listed.

I, understand that session fees are as follows:

Office sessions -- $95.00
Group sessions -- $75.00
Phone sessions -- $80.00

I understand that I am responsible for payment of fees at the time services are provided, unless otherwise arranged with Spring Forest Qigong ® Healing Center.

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.

Please Note:
The Client Information Form should be filled out and sent in only if you are about to make an appointment or have already made an appointment.