Forms

Please check all conditions that apply (past or present):

Please check all symptoms that you are currently experiencing:

Please check any areas you'd like improvement in:

Please describe what you'd like to accomplish with these treatments:

I consent to treatment for myself, my minor child, or my pet and understand that the services provided by the practitioner Gina Jacquart are intended to enhance relaxation and increase communication within the body.

I understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan.

I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided.

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 in nature and will not be shared with anyone without my written consent. I do, however, give the practitioner consent to use my case history and results without using my name. I understand that only the practitioner Gina Jacquart will have access to information in my file to enhance my healing.

I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the practitioner Gina Jacquart and the facility/location where the services are provided.

I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct. I agree to pay for sessions at the time I schedule.