New Client Registration FormPlease complete the registration details below. All information remains strictly confidential.First Name *Last Name *Phone *Email Address *Street AddressCityState/ProvinceEmergency Contact Name *Emergency Contact Phone *Date of Birth *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922OccupationHow did you hear about usAre you currently pregnant *NoYesIf yes, how many weeks?Please indicate if you experience / have experienced any problems or health issues / injuriesPlease provide any information that might be helpful for your therapist(s). We will discuss any concerns with you in person to better understand your health and / or restrictionsDo you have any allergies that might affect your treatment/therapy (fragrances, nuts, oils etc.)Consent *Yes, I agree with the privacy policy and terms and conditions.I have agreed to receive Crystal Therapy and/or Reiki treatments by Lisa Gilmer *YesNoI understand that the treatments will involve gentle energy techniques including: the placement of small crystals and gemstones on my body, guided meditation, and light touch. *YesNoI understand that the treatments may incorporate some Transpersonal Therapy techniques including holistic counselling, guided visualization, creative-expressive therapy and more. *YesNoI understand that Crystal Therapy and Reiki can assist in stress reduction, relaxation, and overall wellness, but is not intended to replace proper diagnostic/medical/clinical/psychological care. *YesNoI understand that I should seek assistance from a licensed medical professional for any serious psychological/physical/emotional ailment that I have. *YesNoI understand that my treatment is conducted on a private property (37 Campbell Street, Hawera), and that all reasonable efforts have been made to ensure it is safe and comfortable for my attendance. *YesNoI accept full liability in the unlikely event of my personal injury while on the above-mentioned premises or as a result of my personal choices or actions undertaken as a result of my treatment. *YesNoBy completing this form you agree that "I have completed this form to the best of my ability and knowledge, and agree to inform my therapist if any of the above information changes at any time" *YesNoConsent *Yes, I agree with the privacy policy and terms and conditions.Submit FormPlease do not fill in this field.
