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Reiki Intake Form -Form Fill
Q1
First Name
Name
Q2
Last Name
Name
Q3
Month
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Q4
Day
Birth Date
1
2
3
4
5
6
7
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10
11
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31
Q5
Year
Birth Date
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
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1987
1986
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1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
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1972
1971
1970
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1968
1967
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1965
1964
1963
1962
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1951
1950
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1945
1944
1943
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1941
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1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Q6
Gender
Male
Female
Q7
Email
Q8
Phone Number
Q9
What are your goals for receiving Reiki?
Pain relief
Relaxation
Addressing a trauma
Other
Q10
Is there any injuries, surgeries, or recent health conditions that you feel the need to share?
Q11
Please sign below if you acknowledge the given information and give your consent to recieve the treatment.
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