Intake Form | The Well-Worn Soul

New Client Intake Form

First name

Last name

Phone Number

Emergency Contact Name

Emergency Contact Number

Address

Date of Birth

Do you suffer from any allergies, disease or illness?

Do you have any metal in your body, an insuline pump or a pacemaker?

Please specify anything we should know about

How did you hear about us?

By Entering, You Consent To This Being Your Electronic Signature:

The information I filled out on this form is truthful.

I accept the Terms & Conditions.

I acknowledge that I have read all the information above, the terms & conditions, and understand it’s meaning.

I have done or will do my own research prior to coming for a service. So when I do come I am well aware of any risks that service may have for myself or others.

I hereby release The Well-Worn Soul and its Practitioners from all Claims and Liabilities arising from any of the Healing Sessions, Classes, Workshops, Teachings and All Other Services offered at The Well-Worn Soul and any aftereffects from that service whatsoever.

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Today's date

By checking here, I consent and agree that this is my electronic signature in lieu of a signature on paper.

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