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Brent Atwater
AMIDI--Animal Medical Intuitive Diagnosis
Animal & Pet
Reincarnation Authority
Atlanta Office: 404-889-1708 USA
Fax: 1-866-212-3298 USA
Email:
Brent@BrentAtwater.com
or AskBrent@live.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 ( Pet animal)
NAME:__________________________________________________ _____________
(last name first)
first
middle nickname
SPECIES_________________
AGE_________
PHOTO: _____
CLIENT BIRTH
DATE:________________ TIME:_____________
PLACE:__________________
Guardian'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 schedule
appointment?______________________________
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IS Email communication easy for you?_______________________
May I use your or
your pet's photos WITHOUT YOUR NAME on my website?
______________
If this is a Pet
Animal Reincarnation consultation you do not need to fill out the
following unless you have other questions.
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?
_______________________________________________________________________
_______________________________________________________________________
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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.
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