Author: Tyler Bernard

Intake Form
Astrolight Healing

NAME: _______________________________	DATE:_____________
ADDRESS: __________________________________________________
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PHONE: Cell _____________ Home ____________ Work ____________
EMAIL ADDRESS: ___________________________
DATE OF BIRTH: _______________
BEST WAY TO CONTACT:  Phone/Call ____ Phone/Text ____ Email ____
REFERRAL/HOW YOU HEARD ABOUT ASTROLIGHT HEALING (Mark X)
1.	Friend/Family Member ____ Name of referral ________________________
2.	Website ____
3.	Flyer ____ Where: ______________________________________________
4.	Business Card ____ Where:  ______________________________________
5.	Other ____ Where/ How : ________________________________________
REASON YOU SCHEDULED THIS APPOINTMENT: 
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WHAT ISSUES WOULD YOU LIKE TO ADDRESS (In order of importance if it applies)
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ALLERGIES:
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MEDICATIONS:
_________________________________________________________________________________________________________________________________________________________________________________________________________

HEALTH CONDITIONS I SHOULD BE AWARE OF:
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ANYTHING ELSE YOU WOULD LIKE ME TO KNOW:
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I agree and certify that the above information is correct and that I have given all information that is important for Tyler Bernard and Astrolight Healing to know and understand about me at this time.
Signature __________________________________________	Date ___________