Date:

Reiki Client Form

(Please Print)
Name: ___________________________________________________________
Phone (home): _______________________ Cell: _________________________
Address: __________________________________________________________
City, State, Zip: _____________________________________________________
Email: ____________________________________________________________
Emergency Contact: _______________________________ Cell ________________
Are you currently under the care of a physician?

Yes ____ No______

If yes, physicians name: _______________________________________________

(Please list current medications and ailments on the back of the form)
Have you ever had Reiki before? _________ If yes, when was your last session?
____________
Do you have a particular area of concern? __________________________________
____________________________________________________________________
Are you sensitive to perfumes or fragrances? _________
Cancellation Policy
If you cannot for any reason attend your scheduled session a 48 hour
cancellation is suggested, 24 hours is required. In the event of an
emergency, with less than 24 hours, the following options are available. You
may re- schedule your appointment within 30 days with no cancellation
charges. Appointments not re-scheduled will incur a $25 cancellation fee
billed to your home address. Please understand that cancellations greatly
affect scheduling and adversely impact myself and other clients. A client
that cancels up to 3 times may be asked for pre-payment of their session.
Clients who schedule and miss their session without notice will be charged a
$40 No Show fee.
Name:
________________________________Signature________________________________