Confidential Healing Data Form | Stillpoint Healing

CONFIDENTIAL HEALING DATA FORM

Select Service Type of service required*

Pranic Healing Hypnotherapy Ancestral Healing Pranic Feng Shui Secret Mantra Healing Access Bars Sessions

Patient's Name*

Address*

Date Of Birth*

Occupation

Phone*

Email*

Family Income*

Sex*

M F O

Marital Status*

Single Married Other

1). Do you smoke

Yes No Rarely

2). Do you take any prescription drugs*

Yes No

If yes, specify

3). Do you drink alcoholic beverages

Yes No Rarely

4). Do you have history of contagious disease*

Yes No

If yes, specify

5). Do you have history of serious physical injury*

Yes No

If yes, specify

6). Do you have history of psychological disorder*

Yes No

If yes, specify

PATIENT'S CONDITION (Symptoms, Complaints and Problems)*

Patient's Photo

Allowed file types: jpg, jpeg, png, gif, webp.

Date*

Healer's Name

I understand and agree to the consent statement.

Consent

I understand that Healing Modalities is not meant to replace conventional medicine but rather to complement and enhance it. If symptoms persist, medical professional is to be consulted. I hereby release the person or persons providing the Healing Modalities from any liability as a result of the services received by me.