New Client Registration Form – Activate With Ang

Name

First Last

Phone

Email

Date of Birth*

Weight

Height

Blood Type

Occupation

Referral

Allergies

Ailments/Illnesses

Medications (Name and what they used for)

Exercise (none, moderate, intensive)

Diet (example, healthy, not healthy)

Challenges at the moment that you would like to work through:

Name a few limiting beliefs about yourself that you would like to release:

Transformation/Goals/Vision for yourself, business and life:

Rate the following from 1-10 (10 being perfect, 1 being the worst)

Energy Levels

Quality of Sleep

Memory

Moods

Skin

Digestive System

Stress Levels

Nervous Energy

Muscle Pain

Joint Pain

Circulation

Consent*

I agree to the Terms and Conditions

Please read carefully and sign at the bottom
I understand that this information that I have given is strictly confidential between the therapist and me. All the information that I have given is correct and I have not left out any information. I accept that the practitioner cannot be held liable for any injury, illness or death based on the nature of the treatment. I have chosen to receive this treatment out of my own free will. I acknowledge that this is a non sexual service and that sexual advances will not be tolerated and that the treatment may be stopped if this is breached at any time and the fee will still be payable. I acknowledge that the treatment is not a substitute for medical intervention or treatment and that no results are 100% guaranteed.

Client Intake Form