Violet Serenity Notes

Date

___________________________________________________________________

First name

Last name

Date of Birth

Day

Month

Year

Address

Home Phone

Mobile Phone

Email Address

Please check the box if you would like to receive your appointment reminder via text message

Emergency Contact Name and Telephone Number

Who Referred you, or how did you hear about my services?

What is your occupation?

Medical Information

Name of GP Surgery & GP

Do you have any current medical conditions? Please include the date of doctor's diagnosis where relevant

Have you undergone any current or recent medical treatment? If so, please advise details:

Are you taking any medication?

Do you have any mental health issues or PTSD?

Are you pregnant? if yes, how many weeks?

Do you have any allergies?

Are there any issues that might affect your session with me? e.g. pacemaker, metal implants, Epilepsy

Do you have any Covid or Flu symptoms?

Have you had Reiki before?

Yes

No

Are you able to lay flat on your back?

Yes

No

Would you prefer to sit during your treatment?

Yes

No

Do you have any specific issues that you hope to work on or heal? e.g. Stress, Anxiety, Pain Relief, Drepression, Illness? Please give details if you are able:

What are your hopes and expectations of your Reiki treatment today?

Cancellation terms apply to your appointment. Please kindly read my cancellation policy here and tick to confirm that you agree. Thank you for your understanding.

Client Declaration

Please tick the boxes as applicable and sign below.

I decalre that information I have given is true and correct and that, as far as I am aware, I can undertake treatment without any adverse effect. I have been fully informed about contraindications and am therefore willing to proceed. I understand that Reiki is not a substitute for medical advice and/or treatment from a GP or hospital doctor and that Reiki Practitioner's do not diagnose.

I give permission for my information on this form to be stored and to be added to Violet Serenity Reiki mailing list for future offers and newsletters.

unsubscribe at any time - send an email to: chloe@violetserenityreiki.co.uk with subject title unsubscribe

Client Signature

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On the Day of your Appointment

Chloe - I will print your information form ready for you to complete the following two questions on the day of your appointment.

Have you drunk alcohol in the last 24 hours?

Yes

No

Have you taken recreational drugs in the last 24 hours?

Yes

No

Client initials on day of appointment to confirm completion of above two questions.

Initials: - _________ Date: - _______________

Appointment Costs

I welcome & support
Neurodiversity

Reiki Client Booking & Information Form

Cancellation Policy

Client Declaration

On the Day of your Appointment

Violet Serenity 2025