Disclosures - Iris Hagen Ratowsky

DISCLOSURE & INTAKE FORM

The following information and form signature is required prior to your initial session with Iris Hagen Ratowsky. Please be sure to fill out and submit this form prior to your session.

NOTE: You must first contact Iris to book your session prior to filling out this form.

Is the client being seen 18 years or older?*
- Yes
- No
Client Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Age*
Primary Phone*
Email*
Enter Email Confirm Email
Home Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact (EC) Information
EC Name*
First Last
Relationship to EC*
(ex. Mother, Father, Child, Aunt, Husband, Friend, etc.)
EC Phone*
Client & Guardian Information
This information is required if the client is a minor.
Client Name*
First Last
Client Date of Birth*
MM slash DD slash YYYY
Client Age*
Guardian Name*
First Last
Guardian Phone*
Guardian Email*
Enter Email Confirm Email
Home Address*
Street Address Address Line 2 City State ZIP Code
Homeopathic and Craniosacral Therapy Disclosure and Notice:
Homeopathy and Craniosacral Therapy are practiced as alternative healing arts in California under Sections 2053.5 and 2053.6 of the Business and Professions Code subject to these requirements and restrictions:
1. That the practitioner states she is not a licensed physician or health-care provider, and
2. That homeopathic consulting and Craniosacral services are not licensed by the state, and
3. That neither homeopathic consulting nor Craniosacral Therapy is represented as or intended to be substitutes for conventional medical diagnosis or treatment and does not diagnose or treat specific pathological conditions or disease symptoms.
Acknowledgements
By signing below, you are agreeing to the following:
1. It is my personal preference to use the homeopathic or craniosacral services provided by Iris Hagen Ratowsky. I understand that these services are not medical treatments and that Iris Hagen Ratowsky is not a licensed physician.
2. I understand that payment is required prior to my appointment and can be made via Venmo or check.
3. I understand that there are no refunds for missed appointments (whether in-person, by phone, or virtual) that were not cancelled at least 48 hours in advance.
By signing below, you are agreeing to the following:
1. I am consenting to the treatment of the minor noted on this form, for whom I am responsible by law, by Iris Hagen Ratowsky.
2. It is my personal preference to use the homeopathic or craniosacral services provided by Iris Hagen Ratowsky. I understand that these services are not medical treatments and that Iris Hagen Ratowsky is not a licensed physician.
3. I understand that payment is required prior to my appointment and can be made via Venmo or check.
4. I understand that there are no refunds for missed appointments (whether in-person, by phone, or virtual) that were not cancelled at least 48 hours in advance.
Client Signature*
Hover your cursor over the white box below and use your mouse or trackpad to sign on your desktop or laptop. If you are on a mobile device, you can use your finger to sign.
Consent*
I have read and agree to honor all office policies and understand the above disclosures and acknowledgements.
Guardian Signature*
Hover your cursor over the white box below and use your mouse or trackpad to sign on your desktop or laptop. If you are on a mobile device, you can use your finger to sign.
Today's Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

DISCLOSURE & INTAKE FORM

Client Information

Emergency Contact (EC) Information

Client & Guardian Information

Homeopathic and Craniosacral Therapy Disclosure and Notice:

Acknowledgements