ReleaseForm

Sharon Azogué LLC
Client History and Release Form

* Indicates required field

Name *

First

Last

Address *

Email (Will not be shared) *

Marital Status *

Number of Children *

How did you hear about me? *

Reason For Visit *

History *

Describe any major illness or chronic health problems past or present *

Which, if any, medications are you currently taking? *

Have you ever been hospitalized for a mental/ emotional condition, and if yes, than when and for what? *

No Yes

Reason for your hospitalization *

Are you currently seeing a physician or therapist, and if yes than for what? *

No Yes

Reason for seeing a physician or therapist *

I understand that my success depends on my own commitment to improving the situation that has brought me here. I realize that Sharon Azogue is not prescribing for, or treating any physical or mental ailments, and do not hold her responsible for them. I release her from any liability whatsoever regarding my session. I agree to inform Sharon of all physical or mental conditions that might affect her work with me. I understand that our sessions may involve healing touch. I authorize that this release form apply to all future appointments as well.

Release: *

Yes, I authorize this release form No, I do not authorize this release form

Date *

Please Type Full Name *

Submit

Sharon Azogué LLC
Client History and Release Form

Services

Sharon Azogué

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Sharon Azogué LLCClient History and Release Form

Services

Sharon Azogué

Subscribe

Sharon Azogué LLC
Client History and Release Form