Alternative Medical Pet Specialist:
Medical Intuitive, Distant Healing
PO Box
475 Southern Pines, NC 28388 USA
NC
Phone: 1.910.692.5206 USA
NC Fax: 1.910.692.5103 Atlanta, GA
Phone: 1.404.242.9022 USA
Email: Brent@BrentAtwater.com
Client Agreement & Release
Please fill
out
these 2 pages completely
& return to NC Office. I,
the owner or legal guardian of (Please print)___________________________________(the
"Client"),
understand that B Brent Atwater, of Energy Work, Inc., is a Medical Intuitive,
Distance Energy Healer,
and intuitive consultant and does not present herself as a medical doctor
nor as possessing any
specific or formal medical training, nor as a licensed, registered or
certified practitioner or counselor.
I seek and it is my intent to hire Ms. Atwater for
Consultation(s) and or Healing Energy Work(s).
No one representing Energy Work, Inc., or Ms. Atwater offers
me any false hope, false expectations,
promises, warranties, or assurances of the success or the outcome of any of
Ms. Atwater's work.
I have read and understand Ms Atwater's fees and that
they are pre paid before my appointment is
scheduled, and non refundable. I agree to the payment conditions
and to pay the total fee amounts for
Ms. Atwater's services in US Funds.
I choose the following service (s). Please write clearly
1.
___________________________________________________________________________________
for ________________Minutes Fee:_______________
2.
___________________________________________________________________________________
for ________________Minutes Fee:_______________
If applicable Ms
Atwater's travel fees are: _________________
Initial Total service fees are:________________
If I pay by debit or credit card , I understand
that by providing the
following information to Ms. Atwater,
and Energy Work, Inc., that I agree to and I legally authorize that the
debit or credit card below be charged
to pay for Ms Atwater's Consultation(s), answers to Email questions and or
Healing Energy Work(s).
If I pay via PayPal, I agree to and authorized that
transaction to pay for Ms Atwater's services. The
PayPal email address is Brent@BrentAtwater.com.
I understand and agree to the following:
a. If I need to reschedule my
appointment, that I am required to
give Ms Atwater's office a 24 hour notice. b. If I miss my
appointment, without giving Ms Atwater's office
a 24 hour notice for any rescheduling, I will be charged the full fee for
Consultations and or Healing Energy
work and or Travel arrangements.
c. I call Ms Atwater for my sessions and
pay the
telephone charges.
I am eighteen (18) years of age or older, of sound mind, and not
under any mind altering drugs. By signing
this agreement, I acknowledge that I have read the above, have thoroughly
reviewed and understand its
contents, and that I am giving my informed consent and it is my intent to
agree to this contract. By my written
acceptance of this agreement, I know this document becomes a legally binding
contract and is confidential.
Owner's or Legal Guardian's
Signature:_________________________________________________Seal
Date: _______________________
Witness: _______________________________________________
As the Owner and or Legal Guardian,
I acknowledge that I have read the above, have thoroughly reviewed
and understand its contents, and that I am giving my informed consent and it
is my intent to agree to this
contract. I
authorize you to work with: ____________________________________________(
the Client).
Signature:_________________________________________________Seal
Date: _______________________
Witness: _______________________________________________
Alternative&
Integrative Medical & Pediatric Specialist: Medical Intuitive, Distant
Healing
PO Box 475 Southern
Pines, NC 28388 USA
NC
Phone: 1.910.692.5206 USA
NC Fax: 1.910.692.5103 Atlanta, GA Phone: 1.404.242.9022 USA
Email: Brent@BrentAtwater.com
Client Agreement & Release page: 2
of 2
The
method of payment for my appointment is: Please check one of the following
Personal Check:__________ Money Order:_________
Pay Pal:_____________
Credit or Debit Card:________ Type of
card:_______________________________________
Name as it appears on the
card:__________________________________________________
Card number :___________________________________________________Please Print
CLEARLY-
Expiration date of card :_______________________
The last three numbers on signature strip:_____________
The Billing Name and Address as it appears on the card's statements:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
You will receive a separate form with instructions for your appointment(s)
when it is scheduled.
Thank you.