Client Intake Form

NEW CLIENT SERVICE INTAKE FORM

First Name

Last name

Address

Phone

Birth Date: Month/Day/Year

What Service Did You Book?

When Will Your Service Be Held: Date and Time

Who Else Is Coming With You?

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

Emergency Contact Person

Emergency Contact Person Phone Number

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?

YES

Do you suffer from any Disease or Illness?

I Acknowledge and Agree that the information on this form is truthful, and I understand that, because Holistic Healing Services and/or other Nibana Salt & Wellness Services 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 other services at this time. I voluntarily agree to assume those risks, and I release and hold harmless Nibana Salt & Wellness and their Team Members from any claims related thereto. I give my consent to receive treatment, classes and all services at Nibana Salt & Wellness and it's Practitioner Team Members.

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

When you come into Nibana Salt & Wellness you are confirming that to your knowledge, you are not experiencing any flue and/or Covid-19 or 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 her you are confirming that you are healthy & responsible for assisting gus with maintaining a safe environment for all those that come to Nibana Salt & Wellness.

We do not claim to heal or cure any health conditions. Nibana Salt & Wellness and Practitioner Team Members recommend all clients do their own research and discuss any services with their doctor prior to booking and 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 and researched all contraindications to any service on the Nibana Salt & Wellness website and elsewhere prior to coming for the service understanding the risks involved.

The information concerning each service is uploaded to the Nibana Salt & Wellness website and is only for informational purposes. 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.

Nibana Salt & Wellness is not 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 belonging will be at your own risk.

I Acknowledge and Agree to the above. Consenting that this be the electronic version of my signature in lieu of a signature on paper.

I have read Niban's Policy and agree to all terms and hereby release Nibana Salt & Wellness, All Practitioners & Team Members from all Claims and Liabilities arising from any and all services offered at Nibana Salt & Wellness as well as any aftereffects from those services

Today's Date

The Healing Place Of Annapolis

NEW CLIENT SERVICE INTAKE FORM

CLICK TO BOOK

Call | Text: 667 . 500 . 2076

Email: nibanasw@gmail.com