Client Release and Contract for Personal Services
               Page 1 of 2
                                  
Be sure to fill in the required spaces marked with the red X
                                                                         between

                                                             B Brent Atwater

     X  ______________________________________________________________________ ("Client") of
            Please print Name    
     X  ________________________________________________________________________
  Address
     I 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.
     In consideration
of the promises and conditions contained herein, I seek and it is my intent to hire
  Ms. Atwater for Intuitive Consultation(s) and or Healing Energy Work(s). As further consideration for
  Ms Atwater's Services, I agree to provide certain current, complete and accurate information about myself
  as required on Ms Atwater's client information form. No one representing Energy Work, Inc., or Ms. Atwater
  offers me any false hope, false promises, expectations,  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. _______________________________________________                Fee:________________ X
                                                                   
      
       2. ________________________________________________               Fee:_________________
                                                                   

   
Additional Fees if applicable: Emergency : ________________           Travel:___________________   
                                                                                     
                                                                       Initial Total service fees are: __
_______________ X

     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. 
This Contract
  shall be governed by and construed in accordance with the laws of the State of North Carolina
.

  X  Signature:_____________________________________________Seal    Date: ___________________  X
   
      Witness: ___________________________________________

      Consent by Legal guardian, Parent or Attorney in Fact.
   As the Parent and or Legal Guardian, or POA,
 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 provide services for: ___________________________________ ( Client).

   X  Signature:____________________________________________Seal    Date: ___________________  X

      Witness: ________________________________________



 


                                                                       
                         
                             Energy Medicine 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 : 1.404.242.9022 USA
                                                               Email:
Brent@BrentAtwater.com                                            
                                                             
                                       
Client Release and Contract for Personal Services page: 2 of  2
                                         Be sure to fill in the required spaces marked with the red X

                    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:_________________________________

          
X Name as it appears on the card:________________________________________________________   

          
X Card number, Please Print CLEARLY:___________________________________________________

          
X Expiration date of card :____________________________

          
X The last three numbers on  signature strip:_____________



           The Billing Name and Address as it appears on the card's statements:

         
  X  _______________________________________________________________________

          
 X _______________________________________________________________________
 
         
  X _______________________________________________________________________

          
 X  _______________________________________________________________________ 
                                    
            You will receive a separate form with instructions for your appointment(s) when it is scheduled.  Thank you.