Angels Guided Healing Phone Sessions

Special 60 minute session for $85.00

Savings of $15.00 through 3/31/13

Purchase a package of 4 sessions for $297.00

Aurasainte D’Amato

ACST, ACBT

* Certified Reflexologist
* Angels Guided Healing & Messages
* Energy Healing
*Graduate of NJ Institute of Reflexology
*Member American Reflexology Association
*Member Associated Bodywork & Massage Professionals
*Aurasainte's #
732-224-8441
*Associated with a Natural Medicine Center
In Holmdel, New Jersey 07733

Email address: aura.damato@gmail.com

Aurasainte's Websites
www.auradamato.com

CLIENT APPOINTMENT FORM

Please print and bring this completed form with you to your appointment
PLEASE PRINT CLEARLY

Aurasainte D'Amato
Certified Reflexologist & Energy Healing Practitioner
Graduate of NJ Institute of Reflexology
Member of The American Reflexology Associations
Member of the Associated Bodywork & Massage Professionals
Holmdel Acupuncture & Natural Medicine Center
732-224-8441 732-888-4910

Date:_______________________________________

Name: ___________________________________________________________
Address:______________________________________________________________
City:___________________________________________ State:_________________

ZipCode________________________________
HomePhone:______________________________________________________
Cell Phone_________________________________________________________
Work Phone ______________________________________________________
EMAIL Address_________________________________________________________ Occupation:__________________________Work Phone:_____________________________ Email:______________________________________________________________________
Referred By:_________________________________________________________________
DOB:____________________________________Are you pregnant________________________
Emergency Contact
Name:___________________________________________________________

Number:__________________________________________________________

Are you currently under a DoctorÊ¼s care?_____If yes, what for?__________________ ______________________________________________________________________

Are you currently taking medication?_____If yes, what?_____________________________________________________________________

PhysicianÊ¼s Name and Phone Number:_______________________________________

ChiropractorÊ¼s Name and Phone Number:_____________________________________

Have you ever received reflexology?_____If yes, when ___________________________________________________________________

Any other holistic or physical therapy?_____If yes, what type?________________________________________________________________________________________

Please check any of the following that apply (past or present)

_asthma __fibromyalgia __lupus__allergies __frequent urination __lyme’s disease

__anxiety __feeling cold __menstrual disorders__AIDS/HIV __feeling hot __neck pain
__arthritis __foot pain __numbness & tingling__back pain __gastrointestinal disorder __night sweats

__blurred vision __gout __palpitation (heart)__breathing difficulties __glaucoma
__poor appetite_cancer __hepatitis __poor coordination__carpal tunnel syndrome __hot flashes __persistent cough__chest pain (or tightness) __headache __restlessness

__chronic fatigue __heart problems __shoulder pain__constipation __hives __spinal misalignment

__depression __high blood pressure __spinal fusion__diabetes __irritable bowel syndrome
__skin problem__diarrhea __immune deficiency __sport injury__difficult concentrating __itchiness __sciatica__digestion problems __insomnia __stress__dizziness/ light headedness __lack of clarity __tendonitis_other (please specify) __migraine headache _low blood pressure___foot fungus ___varicose veins___stomach concerns ___fatigue ____swelling or edema _____numbness or tingling

Other Concerns (please explain)__________________________________________
____________________________________________________________________
______________________________________________________________________

Have you suffered any illness, undergone any surgery (major or minor), or suffered any acute
injuries in the past 6 months? If yes, please explain:_____________________________________________________________________________________________________________________________________________________________

Please share your main concerns for coming today______________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Please Read the Following Information Carefully and Sign Where Indicated

I, (print name) ______________________________________ understand that the reflexology I receive is provided for the basic purpose of relaxation, stress reduction, and relief of tension. If I experience any pain or discomfort during this or any subsequent session, I will immediately inform the practitioner so that the pressure may adjusted accordingly.
I further understand that reflexology is not to be construed as a substitute for medical attention, examination, diagnosis, or treatment and that I should seek the advice of a physician, chiropractor, or any other qualified medical specialist of any physical or mental condition I may have.
I have been made aware that under certain medical conditions, reflexology is contraindicated (should not be performed). I affirm that I have stated all known medical conditions and have updated the practitioner as to any changes in my medical profile. I agree to keep the practitioner updated regarding my medical profile and I affirm that there shall be no liability on the practitionerÊ¼s behalf should I forget to do so. All statements I have made herein are true and accurate to the best of my knowledge.

Signature:______________________________________ Date:__________________