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Client Registration Form

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Full Name

Pronouns

Address (Street, City, Zip code)

Phone Number

Email

Do you want to be added to my mailing list?

Choose one option

Yes

No

How did you hear about KrantzWellness?

Emergency Contact:

Name

Phone

Relationship

Have you had a Reiki session before?

Choose one option

Yes

No

Other complementary healing therapies used:

Anything else you would like me to know?