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Client Release and Contract
on March 11, 2010
Page 1 of 2
Please fill 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 an Integrative
Energy Medicine Specialist:
Medical Intuitive,
Distance Energy Healer,
and intuitive consultant
and
does not present herself as a
medical doctor nor as possessing any
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
integrative Energy Medicine. 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 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 Energy Medicine.
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 rescheduling, I will be charged
the full fee
for Consultations
and or Energy
medicine and or Travel arrangements.
c. I phone Ms Atwater for my sessions and pay the 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. Iit is my
intent to agree to this
contract.
I
authorize you to provide services for:
___________________________________ ( Client).
X Signature:______________________________________Seal
Date: ___________________ X
Witness:
________________________________________
Medical Intuitive
Diagnostic Imaging™ &
Integrative Medicine
PO
Box 475 Southern Pines, NC 28388 USA
NC: 1.910.692.5206 USA Fax: 1.866.212.3298 Atlanta: 1.404.242.9022 USA
Email: Brent@BrentAtwater.com
Client Release and Contract
on March 11, 2010 page: 2
of 2
Be sure to fill in the required spaces marked with
the red X
My payment
method for my appointment(s) 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 instructions for your appointment(s)
when it is scheduled. Thank you.
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