Reiki Waiver - Andra Jo

I hereby give my consent to participate in this in person Reiki Treatment Session and understand that the services provided by my chosen Reiki Practitioner are intended to provide relaxation and reduce stress.

I understand completely that the services provided during this Reiki Treatment Session are in no way a substitute for traditional medical treatment or advice. I am fully aware that my chosen Reiki Practitioner will not offer any diagnosis or recommend any Medical Treatment or Prescribed Medication.

I understand that I must continue to have regular medical check-ups as part of my overall personal health care plan; and I should contact my own certified and licensed medical physician/doctor/health care professional for any physical or psychological ailments or concerns that I may have in order to get proper medical advice.

I agree and understand that my participation in this Reiki Treatment Session is voluntary and that at any time during the Session I can choose to end my participation. I also understand that I may experience ‘self-healing reactions’ during the 48 hours following the Reiki Treatment Session.

I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential and will not be shared with anyone without my written permission.

Finally, I understand that by providing this informed consent I am assuming full responsibility for participating in this Reiki Treatment Session and I hold harmless both my chosen Reiki Practitioner and the facility/location where the services are provided.

First Name*
Last Name*

Date of Birth*

Your Email*

Your Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Please sign below:

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.