Distant Reiki Healing Booking Form Distant Reiki Healing FormFirst NameLast NameMobile NumberEmailDate of Birth (if the reading is for yourself)Is this a gift? Yes NoIf YES, please provide the full name of the recipient.If YES, please provide email / address for the PDF to be mailed.If YES, please acknowledge that any information provided to the recipient are to remain private and confidential. YES I AGREEHave you had Distance Healing before? Yes NoIf YES, when was your last session?Do you have a particular area of concern?Current Medical ConditionsI understand that Distance Healing is a simple, gentle, energy technique that is used for stress reduction and relaxation. I understand that Distance Healing Practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of licensed medical professionals. I understand that Distance Healing 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 ailment I may have. I understand that Distance Healing can complement any medical or psychological care I may be receiving. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. Any use of information in the emailed report is at the readers discretion. Michelle Potter Artist cannot be held responsible for any loss, claim or damage arising out of the use, or misuse of the suggestions made, the failure to take medical advice, or for any material on third party websites. YES I AGREEI understand that my appointment time is reserved for me. I understand and release the practitioner from any/all liability from problems arising as a result of information not given or withheld. YES I AGREEI understand that the information contained in this Form will remain confidential and that it is gathered for treatment and administration purposes. YES I AGREEBy my electronic signature, I acknowledge that I understand and agree to the terms contained in this Consent Form. YES I AGREEElectronic Signature (please type full name here)What happens now? Once I have received your form, I will contact you via email. My preferred method of payment is via PayPal so an invoice will be sent to the email provided. Please be aware that times may vary depending on bookings and my work schedule. From time to time I need to step away from work to recharge. Bookings are not confirmed until you receive email confirmation and payment must be received prior to the commencement of any work.Submit Form