Session Intake &
Medical History Form
I consent that I am in good health, that I have seen my medical practitioner for any/all health concerns I have, and that I do not have any illnesses, symptoms, or medical/health concerns at the time of my scheduled session. I am well.
I consent that I am fully responsible for my health and well being and that I will hold harmless any services provided by my practitioner, Rising Phoenix, Noura Skakri, or any affiliates.
I am fully aware that there will be NO Refunds for any elective procedures under any circumstances.
Please list an emergency contact with a full name & phone number. You may list 2, but only 1 is required. Thanks!
List any drug, makeup, skin or food allergies (i.e. soaps or cleansers):
Have you recently undergone a skin peel?
Do you have, or have you had, any of the following conditions? Please check all that apply
Reiki Clients Only: I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological aliment I may have.
Pregnant Clients Only: I completely release my session facilitator from any liability that may arise as a part of my session. I understand that my massage therapist will not diagnose conditions nor prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that massage does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional and be advised I may experience a pregnancy massage prior to scheduling a session.
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Thank you for your cooperation, time, and honesty in filling out this form.
I look forward to the opportunity to serve you!