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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.
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