Client Intake Form

NEW CLIENT SERVICE INTAKE FORM

Client's First Name*

Client's Last Name*

What Service Did You Book At Nibana?

When Will Your Service Be?

Please Provide Date & Time

Please Name Other People Who Are Coming With You:

Parent or Legal Guardians Full Name in the case of a minor under the age of 18yrs

Client's Phone #*

Please add your phone number if you are the Adult Client, Parent or Legal Guardian of a minor

Client's Email Address*

Please add your email address if you are the Adult Client, Parent or Legal Guardian of a minor

Client's Date Of Birth

Please type the date of birth of the person who will be having a healing session, class or other as follows: month/day/year

Client's Address*

Please add your full address including your zipcode

Emergency Contact Person's Full Name*

Emergency Contact Person's Phone #*

At Nibana we have a Team of Healers that work together to assist clients on their healing journey. Do you give permission for us to share your information with Team Members to enhance your healing experience if we feel it is beneficial for your Healing purpose?

Your information will only be shared if you have/are booking sessions with other Nibana practitioners.

Please answer YES or NO below as way of your consent to the above:*

Do you suffer from any Disease or Illness?*

Please type in NO if you do not | Please type YES and explain if you do:

How did you hear about us?*

By checking here, you are consenting and are in agreement that this be your electronic signature in lieu of a signature on paper and you confirm that:*

Yes I Consent To This Being My Electronic Signature:

I Agree:*

That the information on this form is truthful, and I understand that, because Holistic Healing Services and/or other Nibana Salt & Wellness Services (Healing Haven, the Inner Sanctum Salt Cave, HaloIr Sauna, Amethyst BioMat, Vibration Plate, School Of Wisdom and All Services offered) sometimes involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment, classes, and all services at this time, I voluntarily agree to assume those risks, and I release and hold harmless Nibana Salt & Wellness and Team Member Staff from any claims related thereto. I give my consent to receive treatment, classes and all services from Nibana Salt & Wellness and its Practitioners.

I Agree:*

Any persons seeking the services of Nibana Salt & Wellness must be at least 18 years of age or accompanied by a legal guardian.

I Agree:*

When you come into Nibana Salt & Wellness you are confirming that to your knowledge, you are not experiencing any flu and/or Covid~19 or any variant symptoms. You have not been in contact with anyone who was tested positive or had symptoms within the last 7 days. With your presence here you are confirming that you are healthy & responsible for assisting us with maintaining a safe environment for all those that come to Nibana Salt & Wellness.

I Agree:*

We do not claim to heal or cure any health conditions. Nibana Salt Cave & Wellness and Team Member Staff recommends all clients do their own research & discuss any services with their doctor prior to booking & coming for a service to make sure the service is the correct one for their health condition. It is the client’s responsibility to have read & researched all contraindications to any service on the Nibana Salt & Wellness website & elsewhere prior to coming for that service and understand & acknowledge all and any risks involved.

I Agree:*

The information concerning each service uploaded to the Nibana Salt Cave & Wellness website is for informational purposes only. We highly recommend that further research should be achieved by the client. The information found on the website should not be used for self-diagnosis, treatment, or justification in accepting or declining any of Nibana Salt & Wellness services, classes or other.

I Agree:*

Nibana Salt & Wellness will not be responsible for any damage, theft, or loss of any personal items a client brings into the wellness center. We do not have lockers so leaving personal belongings will be at your own risk.

I Agree:*

By checking here, you are consenting and agree that this be your electronic signature in lieu of a signature on paper and you confirm that: You acknowledge that you have read all the information above and understand it’s meaning. You have done or will do your own research prior to coming for your service so when you do come you are well aware of any risks that service may have for you. You hereby release Nibana Salt & Wellness and Team Member Staff from all Claims and Liabilities arising from any of the Healing Sessions, Classes, Workshops, Teachings and All Other Services offered at Nibana Salt & Wellness and any aftereffects from that service whatsoever.

Date*

Date Selector

Thank you for completing and submitting your Service Intake Waiver Form, we appreciate you taking time to do this. We will be in touch shortly. In the meantime please receive much Love n'Light We look forward to seeing you soon!

The Healing Place Of Annapolis

NEW CLIENT SERVICE INTAKE FORM

CLICK TO BOOK

Call | Text: 667 . 500 . 2076

Email: nibanasw@gmail.com