Medical Intuitive
Diagnostic Imaging™
& Integrative Medicine
Box 475 Southern Pines, NC 28388 USA
NC
Phone: 1.910.692.5206
Fax: 1.866.212.3298 Mobile: 1.404.242.9022 USA
Email: Brent@BrentAtwater.com
08/27/2009
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
NAME:__________________________________________________ _____________
(last name
first) first middle nickname
PARENT'S NAME:________________________________________________
______________
CLIENT BIRTH DATE:________________ TIME:_____________ PLACE:__________________
OCCUPATION:________________________________ Please include CLIENT
PHOTO: _____
HOME
ADDRESS:_________________________________________________________
__________________________________________________________
__________________________________________________________
HOME PHONE:___________________________ EMAIL HM: ____________________________
HOME PHONE 2:_________________________ CELL:_____________________________
OFFICE
PHONE:_________________________ EMAIL OFF:___________________________
PET'S NAME:___________________________ SPECIES_________________ AGE_________
Your pet's Picture (if it's the
client) :___________
Alternative contact:_______________________________________________
Phone:_________________________________________________________
Referring Physician /Specialist/ Practitioner:_________________________________________
____________________________________________________________________
When is a good
time to call to schedule your appointment?____________________________
IS Email communication easy for you?_______________________
What are convenient times for you to have an
appointment?__________________________
May I use your or your pet's photos
WITHOUT YOUR NAME on my website?
______________
Time-Zone Converter
for EST appointments
B Brent Atwater- Client Information Form p 2
What issues do you want healed or addressed?
This section is not necessary if you are having a Body Scan
______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Who are your Medical / Holistic and Integrative providers?
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What Alternative treatments are you currently working with?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
What
Medicines or Herbs are you currently taking?
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
Additional Comments about things that you would like me to know that you
feel would
be helpful information in assessing your issues and facilitating
your healing journey.