Please read, sign, and fax this
Web page to me BEFORE I begin my work with you. My fax
number is 774-293-1005. Thank-you.
I freely acknowledge that I am
fully aware that Marcella Regal is not a
medical doctor, or any other kind of medical practitioner
and she has not represented herself in any way as possessing
any medical expertise or medical training whatsoever and she
has not prescribed, diagnosed, treated or recommend any
particular treatment, medication, or substance for me in
respect of my injury, ailment, or disease that I may
I have not been cajoled, coerced, threatened, or persuaded
by Marcella Regal to undergo or partake in any
particular treatment, medication, or substance - and that I
freely acknowledge that any unorthodox or unusual treatment
or medication or substance that I may utilize is done with
my full awareness and acknowledgement that it is of my own
I, the undersigned, for myself, my heirs, hereby release and
forever discharge Marcella Regal, from any and all
actions, causes of action, claims and demands for or by
reason of any damage, loss or injury, to person and property
which heretofore has been or hereafter may be sustained in
consequence of attending a workshop, or taking of any
medication, substance, or treatment which I may use or
consume in any respect of and for any attempts by myself or
anyone on my behalf to cause temporary or permanent relief
from the symptoms of any injury, ailment, or disease with
which I have been or will be diagnosed.
I have read and understand
that Marcella Regal's fees are to be prepaid
before my appointment is scheduled and that the fees are
non-refundable. If i need to reschedule my
appointment, I will not be entitled to a refund unless I
have provided 24 hours notice. If I miss my
appointment I will not be entitled to a refund.
A Gifted Healer performs massage services for therapeutic purposes only. It is understood that any inappropriate behavior such as excessive drinking, drug use, illicit or sexually suggestive remarks, or advances made by the client will result in immediate termination of the session, and client will be liable for payment for the "full" scheduled appointment. After the dispute is evaluated by A Gifted Healer, and we determines that the client was at fault, we has the right to process the client's credit card.
City, State, ZIP or Region
Referring Physician & Phone (if applicable)
Date of Birth
Alternate Contact & Phone
What are your requested appointment times & dates?
When is a good time to call to schedule your appointment?
What issues do you want healed or addressed?
What alternative treatments have you received or are
currently working on?
Please list all medications and herbs that you are taking
Additional comments about things you would like me to know
that you feel would be helpful information for me to know in
assessing your issues and facilitating your healing.
If you are receiving a
Shiatsu, please do not make an appointment if you
have the following conditions: fever, cancer, leukemia, skin
infections, contagious diseases, pregnancy (first
trimester), recent surgery, injury or trauma within 24
hours, intoxication due to alcohol or drugs. Do
you have any of these conditions (please circle):
If you are receiving energy
healing, I need to know if you have diabetes or heart
disease beforehand. Do you have any of these
conditions (please circle): YES/NO
ADDITIONAL INFORMATION FOR
PLEASE FAX OR EMAIL A PHOTO