Client Intake Form
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Name
Emergency Contact Name
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Back Pain
Pain
Fatigue/Tiredness
Sleep Restful
I declare that the above information is true and correct and indemnify Transcend Healing & Kinesiology of any liability for any false or misleading statements given. It is understood and accepted that the session provided by Transcend Healing & Kinesiology is of a remedial therapeutic energetic nature and not of a diagnostic/curative approach. It is also understood and accepted that the results of the session are not guaranteed in any way. The information gathered here, as well as all notes and information taken in every session, is kept confidential, safe and secure. It will remain the property of Transcend Healing & Kinesiology as part of client history records. I further understand that payment is to be made at the time of the service and can be made by either cash, direct debit or EFT. I agree to give 24 hours’ notice for cancellation of any appointment or a fee of 50% of the consultation fee will be charged. I hereby give permission for Natalie Yeats of Transcend Healing & Kinesiology to conduct a Kinesiology session on me.