Alternative Medical Pet Specialist: Medical Intuitive,
Distant Energy Healer
Box 475 Southern Pines, NC 28388 USA
NC
Phone: 1.910.692.5206
Atlanta, GA Phone: 1.404.242.9022 USA
NC Fax: 1.910.692.5103 Email: Brent@BrentAtwater.com
Client Information
Form
All client information is strictly confidential and secure.
Please fill this out completely, and Mail, Fax or email to NC Address
listed above. Thank you
CLIENT
NAME:__________________________________________________ _____________
(last name
first) first middle nickname
SPECIES_________________ AGE_________
Please include CLIENT PHOTO: _____
CLIENT
BIRTH DATE:________________ TIME:_____________ PLACE:__________________
OWNER'S NAME:______________________________________________________________
OCCUPATION:___________________________________________________________
HOME
ADDRESS:_________________________________________________________
__________________________________________________________
__________________________________________________________
HOME PHONE:___________________________ EMAIL HM: ____________________________
HOME PHONE 2:_________________________ CELL:_____________________________
OFFICE
PHONE:_________________________ EMAIL OFF:___________________________
Alternative contact:_______________________________________________
Phone:_________________________________________________________
Referring Veterinarian /Specialist/ Practitioner:_________________________________________
____________________________________________________________________
_____________________________________________________________________
When is a good
time to call schedule your appointment?______________________________
IS Email communication easy for you?_______________________
What are convenient times for you to have an
appointment?__________________________
May I use your or your pet's photos
WITHOUT YOUR NAME on my website?
______________
Time-Zone Converter
for EST appointments
B Brent Atwater- Client Information Form p 2
What issues do you want healed or addressed?
This section is not necessary if your animal is having a Body Scan
______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Who are your animal's Medical / Alternative providers?
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
What Alternative treatments are you currently working with?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
What are you currently feeding your pet each meal per day?
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
What
Medicines, Supplements or Herbs is your pet currently taking?
How often?
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
Additional Comments about things that you would like me to know that you
feel would
be helpful information in assessing your animal's issues & facilitating
your pet's healing journey.