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Client Intake / Disclaimer Form
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Name
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Phone
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Date of Birth
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Please list all your health issues and conditions presently concerning you:
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Please list any and all your health issues you have experienced in the past. Please list as many as you can and go back as far as memory will serve. (Physical and Emotional)
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What are your general/long term goals? What do you hope accomplish? Achieve? Please describe in detail.
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Do you exercise regularly? For how long?
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Caffeine per day? How many?
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Food Cravings? Please List:
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Hobbies?
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Today's Date:
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Disclaimer
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Please read carefully. I have stated all conditions that I am aware if and this information is true and accurate. I will inform the healer of any changes in my health care. Pranic Healing is not intended to replace orthodox medicine, but rather to complement it. If symptoms persist or the ailment is severe please immediately consult a Medical Doctor and a certified Pranic Healer. PranicHealers are not medical doctors. Selecting "Agree" and submitting this form indicates acceptance of an electronic signature.
I UNDERSTAND THAT: MCKS PRANIC HEALING® practitioners are not licensed physicians or surgeons -- unless they have already learned MCKS PRANIC HEALING® after receiving an MD/DO degree. MCKS Pranic Healing® is not meant to replace conventional medicine but rather to complement and enhance it. If symptoms persist, I agree to consult a medical professional. MCKS PRANIC HEALING® sessions are not licensed by any state. They are complementary to any state-licensed healing practices or services. MCKS PRANIC HEALING® practitioners do not physically touch the client's body, diagnose diseases, prescribe any drugs/substances or make any health claims or guarantee any outcomes. Although the goal is to improve my health and well-being, I understand that unexpected or unanticipated results may occur. I agree to provide updated and current information in the event that the status of any of the stated conditions changes and failure to do so is at my own risk. Any information and opinions expressed are intended to address specific questions or situations, and are not designed to constitute advice or recommendations as to any disease, ailment, or physical condition. Health Through Prana and the US Pranic Healing Center does not make any warranties about the completeness, reliability, and accuracy of any information. I am responsible for my own safety and any action I take upon the information given is strictly at my own risk. I should not act or rely upon any information without seeking the advice of my personal physician or any other professional. Health Through Prana and the US Pranic Healing Center will not be liable for any direct, indirect, consequential, special, exemplary or other damages that may result, including but not limited to, economic loss, injury, illness, death, or any injuries or damages which result from another's negligence or fault. I accept all risks associated with this activity and voluntarily assume full responsibility for all the consequences. I hereby release Health Through Prana and the US Pranic Healing Center from any liability as a result of the services I (or any minor on whose behalf I sign this agreement) have received. By submitting this form, I acknowledge that I have read and agreed to the terms of this liability disclaimer agreement, indicating my electronic signature.
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******* Please complete and submit the Client Intake Form above before booking your session. *******