Waiver Form

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Do you have any concerns?

Are you OK with physical touch during your session?

Yes

Do you have a pacemaker?

Yes

Are you diabetic?

Yes

Do you have high blood pressure?

Yes

Additional health information

Signature

I understand that Reiki is intended to be a complementary therapy and that it is not a substitute for medical diagnosis and treatment. I also acknowledge that the Reiki practitioner does not diagnose conditions, or prescribe medical treatment. I have discussed Reiki with my primary care physician, and have their approval to integrate Reiki sessions into my overall treatment plan. I hereby release Andrea Davis and LilOhmCreations from any claims, demands, and causes of action arising from my participation in Reiki sessions.

Today's Date

YYYY

This form ensures that all parties are informed and agree on the nature of Reiki therapy, its potential benefits, and limitations.