Client Information Form

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

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
DATE: _____________________________________________

CLIENT NAME:__________________________________________________ _____________
(last name first) first middle nickname

PARENT’S NAME:________________________________________________ ______________

CLIENT BIRTH DATE:________________ TIME:_____________ PLACE:__________________

OCCUPATION:________________________________
Please include CLIENT PHOTO: _____

HOME ADDRESS:_________________________________________________________

__________________________________________________________

________________________ POSTAL CODE:_________________________

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:_________________________________________

____________________________________________________________________

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

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Who are your Medical / Holistic and Integrative providers?

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What Alternative treatments are you currently working with?

_________________________________________________________________________

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What Medicines or Herbs are you currently taking?

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Additional Comments about things that you would like me to know that you feel would

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