Tranquil Retreats - ® OFFICIAL Health & Wellness | Consciousness Expansion

QI GONG Therapy / LIVE Energy Diagnostics (LED) Consent Form

Please complete the pre-assessment & consent form below. Filling in the form prior to your session will save time at the session giving you more time for the direct interaction of your session. Please fill in as much detail as you can. Thank you.

Print Full Name

Date of Birth

Occupation

Tel/Mobile contact no:

Please state in full any medical condition or physical injury, past or present, including surgical procedures as well as any injections, pills, tablets or medicines prescribed by your doctor/pharmacist. (If unsure please speak to Shi XingFa during your session) Include any other information that may be relevant to you.

Why are you having QI GONG THERAPY / LED Session (list ALL relevant areas)?

How did you hear about us?

Statement of Consent

I consent to having QI GONG Therapy / LED session. I understand that I can refuse treatment at any time and I understand that my personal data will be held in accordance with UK law and with Tranquil Retreats Data Protection Policy (details can be found on Tranquil Retreats website)

We may contact you from time to time with information that may be relevant you.

Please Note: You may unsubscribe from receiving contact from us at ANY TIME by contacting us – info@tranquil-retreats.com or 07984 665 331. For any information about our GDPR compliance policy please contact us.

Date:

Signature:

Disclaimer

I hereby acknowledge that Shi XingFa has no liability, whatsoever, as a result of my participation in QiGong therapy/LED sessions and that I take full responsibility and liability for any injury, or loss, howsoever caused or sustained, arising directly or indirectly from participating in QiGong therapy/LED sessions. Please consult your physician or health care professional regarding particular health matters. Your consent disclaims any liability arising directly or indirectly from QiGong therapy/LED sessions.