Reiki Forms First, please fill out the Reiki Consent and Intake Form then you’ll be redirected tobook your appointment Reiki Consent & Intake Form Name * First Name Last Name Email * Birthday * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Emergency Contact Name * First Name Last Name Emergency Contact Phone Country (###) ### #### Please Mark The Box To Consent I confirm I am at least 18 years of age, or have parental / guardian permission. I have elected, by my own decision, to have a Reiki therapy session. I confirm that I am not under the influence of recreational drugs or alcohol. The procedure, including the process and objective, has been explained to me before undergoing Reiki. I understand that Reiki is a simple, gentle, hands-on energy technique used for stress reduction and relaxation. I understand that a Reiki session is not a substitute for medical or psychological diagnosis and treatment. I also understand that it is not massage therapy. I understand that it is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that participation is voluntary and that at any time I may choose to end my participation. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level to relaxation needed by the body to heal itself I have been given the opportunity to ask questions regarding any benefits, risks, or possible complications of the procedure. I have followed all pre-treatment care instructions as they have been explained to me. I understand all aftercare procedures for Reiki as they've been explained, and I intend to adhere to the instructions given to me. I understand that it is important to provide feedback during my treatment, and will inform my Reiki Practitioner of any pain or discomfort during the session. With my signature below, I confirm that I have read fully and understand the information in this consent form and all details included. I have provided an accurate account of my medical history including any medications I take or intend to take, and any medical procedures I intend to undergo. By signing below, I agree to accept all and full responsibility for any risks, injuries, damages, or side effects that may occur as part of the procedure. I will not hold my Reiki Practitioner (recorded below) responsible for any conditions present, but not disclosed at the time of treatment, that may affect the treatment. * How did you hear about Amy Conn Reiki? * Web search Web site From Amy Word of mouth Newsletter Other Message (optional) Have you ever had a Reiki session before? * Yes No If yes, when was your last visit? What is your goal for this Reiki session * List any specific area(s) of concern: Do you have any difficulty lying on your back for the entire session? * Yes No Do you have any sensitivity to perfumes or fragrances? * Yes No Are your feet sensitive to touch? * Yes No Are you comfortable with a light touch during a Reiki session? * Yes No Medical history Please write your medical history below Are you pregnant * Yes No If you are pregnant, how far along and are there any concerns? Do you suffer from chronic pain * Yes No If yes, what makes it feel better or worse? Are you taking any medications? If so, please list Have you had any orthopedic injuries If yes, where? Please check if any of the following conditions apply to you: Cancer Fibromyalgia Join replacement Diabetes Stroke Heart attack Sprains/Strains Headache/Migranes Arthritis Numbness Kidney Dysfunction High/low blood pressure Blood clots Depression Anxiety With my signature below, I confirm that I have accurately completed the above information to the best of my knowledge. I agree to notify my Reiki Practitioner of any other relevant information that may affect my treatment, including any changes to the information above. I agree to communicate with my Reiki Practitioner about any pain or discomfort experienced during or after the procedure. I release my Reiki Practitioner of any and all liability of injury or damages that may arise because I have not represented my medical history accurately. * Thank you! Taking you to the scheduling page … Thank You! Sign up with your email address to receive news and updates. Email Address Sign Up Thank you!
