Well of Life Center for Holistic Healthcare

New Client Brain Integration Technique Paperwork

New Client Appointment Checklist

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Complete and submit form below

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No makeup, perfume, lotions, or deodorants

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Drink plenty of water prior to your session
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Do not come hungry; be sure to eat prior to your session

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced.

Please contact our Client Advocate if you have any questions or need additional information.

New Client Form

CLIENT INFORMATION:

In Case of Emergency, please contact:

Please provide details if any or all of the following applies to this client:

The following questions are part of the background necessary to evaluate your learning problems. A number of factors involved with the prenatal, birth, and early postnatal periods are sometimes associated with learning difficulties. Please briefly indicate if any of the listed items below apply and note any that are not included in this list.

1. Mother of Client

2. Client's Birth

MEDICAL HISTORY

PLEASE ADVISE IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

BRAIN INTEGRATION TECHNIQUE BEHAVOIRAL CHECKLIST

Please click HERE to read our Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of Agreement and Release of Liability.

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