Client Agreement


Client Release and Contract
on                                ,                      ,   2015                             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 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 are pre paid BEFORE my appointment is scheduled, and non refundable. I agree to the payment terms and conditions and to pay the total fee amounts
for Ms. Atwater’s services in US Funds. I choose the following service (s). Please write clearly1. _______________________________________________ Fee:________________ X2. ________________________________________________ Fee:_________________Additional Fees if applicable: Emergency : _______________ Travel:________________Initial Total fees are: _________________ XIf 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 Services. I agree to pay for the any fees if my card is declined.
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. It is my
intent to agree to this contract.
I authorize you to provide services for: ___________________________________ ( Client).

X Signature:______________________________________Seal Date: ___________________X

Witness: ________________________________________

MIDI Medical Intuitive Diagnostic Imaging™ & Integrative Medicine
Email: Brent@BrentAtwater.com


C
lient Release and Contract on                                ,               , 2015                              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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