Intake Form

After you have booked your appointment with Rosemary, please fill out and email the following form prior to your session date. Asterisked lines indicate required entries. There is an automatic submit button below the form. Thank you!

NAME*
First Last
DATE OF BIRTH*
TIME AND LOCATION OF BIRTH (If you don't know this information, leave blank and proceed to next section.)
ADDRESS*
Street Address City State / Province / Region ZIP / Postal Code Country
MOBILE PHONE*
EMAIL*
WHAT TYPE OF SESSION HAVE YOU BOOKED? (INTUITIVE BODY READING, ENERGY HEALING or HEALTH ASTROLOGY SESSION)*
BRIEFLY DESCRIBE THE REASON FOR YOUR SESSION IN A FEW SENTENCES.*
WHEN DID YOU FIRST NOTICE SYMPTOMS RELATING TO THE ISSUE(S)?*
LIST CURRENT MEDICATIONS, HERBS AND/OR SUPPLEMENTS THAT YOU'RE TAKING.
PLEASE INDICATE HOW YOU WILL BE PAYING FOR YOUR SESSION BY SELECTING ONE BUTTON BELOW. IF PAYING BY CREDIT CARD OR PAYPAL, GO TO: http://rosedovehealing.com/payment/ AFTER SELECTING YOUR BUTTON HERE.*
- Cash
- Check
- Credit Card
- Paypal
HOW DID YOU LEARN ABOUT ROSEDOVE HEALING SRVICES? PLEASE LIST THE NAME OF THE PERSON(S) WHO REFERRED YOU.*
Declaration of Release of Liability
Except in the case of gross negligence or malpractice, I, or my representatives, agree to full release and hold harmless, Rosemary Serluca-Foster and Rosedove Healing from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).
Use your mouse or track pad to sign below.
Signature*
Date
MM slash DD slash YYYY
Energy Medicine Professional Association Insurance
The liability policy that the Healing Touch Professional Association (HTPA) provides to qualified members covers the member's practice operations for professional liability (coverage if client alleges malpractice), general liability (coverage if client alleges injury [accidents] due to member's negligence), and products liability (coverage if client alleges reaction to product). The insurer will also defend the member if someone sues alleging their wrongdoing in covered losses: those legal expenses are provided in addition to the policy limits.

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