Annette Frost-JensenSacred Vessels + Sacred Space, llc Client Intake/Release of Liability Name * First Name Last Name Email * Date of Birth * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### How did you hear about me? Friends Social Media Organic Search Other Brief health history - please date major accidents, surgeries, trauma and any current health conditions. * Do you have any allergies ? If so, please describe. * Are you currently taking any medications ? If so, please describe ? * I understand that I will be participating in a shamanic healing session. I understand that Annette Frost-Jensen is not a trained psychotherapist, physician or medical professional. I understand that Annette Frost-Jensen works energies and imagery. I accept my own responsibility to make meaning of the healing experience. The session may consist of hands-on, tobacco work, songs, shamanic extractions, etc. This is not a medical treatment nor is there any promise of a cure. I agree to hold Annette Frost-Jensen and Sacred Vessels+ Sacred Space,llc harmless for any reactions resulting from this treatment (or series of treatments). I understand that Shamanic Practitioners are NOT licensed for medical treatment or massage. Understanding the above, I give my permission for the treatment. * Yes, I Consent Thank you!
