ENERGY MEDICINE INTAKE FORM. Name: Date: Address: Occupation: Telephone Number- Home: Work: Emergency Contact- Name: Phone: Relation:
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1 ENERGY MEDICINE INTAKE FORM Name: Date: Date of Birth: Age: Address: Occupation: Telephone Number- Home: Work: Mobile: Emergency Contact- Name: Phone: Relation: How did you hear about me: Other Health Care Providers: HEALTH INFORMATION Please list your health concerns (physical, emotional, or psychological) in order of importance to you and the date of onset:. Age: 2. Age: 3. Age: 4. Age: 5. Age:
2 Please list your most stressful life experiences (physical or psychological):.age: 2.Age: 3.Age: 4.Age: MEDICAL HISTORY Have you had any surgery in the past? If so, please let us know what was done and when: SURGERY Yes No. Date: 2. Date: 3. Date: 4. Date: If you have had any x-rays, lab tests, or other diagnostic tests done in the past year, please explain: 2
3 Are you diabetic? Yes No Are you under more stress than usual? Yes No Do you have problems sleeping? Yes No Do you have high blood pressure? Yes No Have allergy symptoms been a problem? Yes No Have you been bothered by skin rashes or itching? Yes No Do you get short of breath easily? Yes No Have you had problems with asthma? Yes No Do you have digestion problems? Yes No Please describe the emotional climate of your home: Rate your stress level (0 = high) In your everyday life, your present faith/spiritual practices are (0 = very important): Please rate your level of motivation to affect change in your health (0 = motivated). Is there anything else you would like to tell us about your current state of health? 3
4 FEE SCHEDULE NEW CLIENT-INITIAL CONSULTATION AND FOLLOW UP SESSION- Energy Medicine $60.00 Includes: Consultation and Examination $5 and Follow up $45 - One Hour Session. NEW CLIENT-INITIAL CONSULTATION AND DISTANCE SESSION-Energy Medicine by distance on skype $70.00 Includes: Consultation and Examination $5 and Distance Session $55 - One Hour Session. FOLLOW-UP SESSION- Energy Medicine $45.00 Includes: Energy Balancing - 30 Min Session. SAME DAY SESSION - Energy Medicine $40.00 Includes: Energy Balancing, more than one session in a day-allowed up to five - 30 Min Session. FAMILY PETS SESSION- Energy Medicine $55.00 Includes: Distance Energy Balancing for Pets - 30 Min Session. DISTANCE SESSION- Energy Medicine $55.00 Includes: Long Distance Energy Balancing, for those unable to come into the office - 30 Min Session. EMERGENCY DISTANCE SESSION- Energy Medicine $60.00 Includes: Emergency Off Hours Long Distance Energy Balancing CRANIOSACRAL -30 MIN $45.00 Includes: 30 Minute Craniosacral Session CRANIOSACRAL -45 MIN $70.00 Includes: 45 Minute Craniosacral Session PAST LIFE REGRESSION $ Includes: 2 Hour Past Life Regression Session, Transcript and Recording *All fees reflect HST *Cancellation Policy: $50.00 missed appointment fee will be charged, if the appointment was not cancelled 24 hours in advance. * For Distance Sessions only, please fill out the credit card information below. Credit Card Type: Credit Card Number: Expiry Date: CVV (3 digits at the back of CC): All credit card information is kept confidential and secure *All sessions (other than distance sessions) must be paid by cash, cheque, PayPal or Internet Transfer upon completion. My signature ensures that I have been made aware of the costs involved and I accept full responsibility for payment. Client Signature or Parent/Guardian Signature Today s Date
5 Genevieve Cigna Tel Web Address 42 Woolwich St. Guelph, NH 3X2 DECLARATION AND CONSENT TO TREATMENT Even the gentlest therapies have their complications in certain physiological conditions such as pregnancy and lactation, in very young children, or those with multiple medications. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease. It is very important that you inform your Holistic Energy Practitioner immediately of: Any disease process that you are suffering from If you are on any medication or over the counter drugs If you are pregnant, suspect you are pregnant, actively attempting to become pregnant or you are breast-feeding There are some slight health risks to Energy Medicine. These include but are not limited to: Aggravation of pre-existing symptoms within the following 24 hours I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself when law requires it. I understand that I may look at my medical record at anytime and can request a copy of it or have a report drawn up by paying the appropriate fee. I understand that information from my medical record may be analyzed for research purposes and that my identity will be protected and kept confidential. I understand that my health care professional will answer any questions that I have to the best of his/her ability. I understand that the results are not guaranteed. I do not expect the Holistic Energy Practitioner to be able to anticipate and explain all risks and complications. I will rely on the Holistic Energy Practitioner to exercise judgement during the course of the procedure which they feel at that time is in my best interests, based on the facts then known. I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. If I am unable to make my appointment I must provide advance notification within 24 hours in which case no charge will be applied. THIS IS TO ACKNOWLEDGE that I have been informed and I understand that: Any treatment or advice provided to me as a client is not mutually exclusive from any treatment or advice that I may now be receiving or may in the future from another health care provider; I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Ontario; No employee, student or anyone else under the Clinic's direction or control is suggesting or advising me to refrain from seeking or following the directions of another health care provider; The treatment and therapies rendered or recommended by this clinic may be different than those usually offered by a medical doctor or other health care provider. I DECLARE that I have received a full and complete explanation of the treatment or services and that I have read and agree with its contents. I AGREE to pay my full account at the time of each visit or treatment, including fees for services, administrative fees as well as other applicable fees. Full Patient Name (Please Print) Patient Signature or Parent/Guardian Signature Holistic Energy Practitioner Date of Consent
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THE ORIENTAL INSURANCE COMPANY LIMITED Regd. Office: ORIENTAL HOUSE, P.B. No. 7037, A-25/27, ASAF ALI ROAD, NEW DELHI - 110 002 PROPOSAL FORM FOR OVERSEAS MEDICLAIM- BUSINESS AND HOLIDAY (To be submitted
The Center for ADHD, Inc.
Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address
Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
Opioid Treatment Agreement
Opioid Treatment Agreement 1. I understand that my provider and I will work together to find the most appropriate treatment for my chronic pain. I understand the goals of treatment are not to eliminate
GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE
Page1 GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE By: Date of Birth: (Print Name) (mm/dd/yyyy) This advance directive for health care has four parts: PART ONE HEALTH CARE AGENT. This part allows you to choose
Beach Cities Medical Weight Loss
Beach Cities Medical Weight Loss PATIENT HEALTH HISTORY Name: Address: City/State: Zip: Phone: (home) Cell: Date of Birth: Occupation: Driver s License # Expiration: Emergency Contact Name: Relationship:
What is a Living Will?
What is a Living Will? With today s advances in medical technology, the process of dying can be prolonged by what are often referred to as artificial means. A Living Will can be used to let your healthcare
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
INTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy
Patient s Name: D.O.B.: Age: Address: City: State: _ Zip Code: Home Phone #: Cell #: _ Business #:_ Social Security Number: E- mail Address: Referring Physician? _ How do you hear about us: Dr. Referral