Intake Form

Client Intake Form

* Indicates required field

Name *

First

Last

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

CLIENT HISTORY AND INFORMATION

Do you have an aversion to the use of Essential Oils? *

Do you have any current injuries? If yes please list: *

Are you currently taking any medications? If yes, please list: *

List Medications *

Are you currently pregnant? *

Are you epileptic or prone to seizures? *

Are you sensitive to light? *

Are you taking photosensitive medicines where you have been guided to stay out of the sun by your doctor? If yes, consult your doctor prior to use. *

I give Leslie Schroer, permission to touch me as is necessary to perform modality techniques and to assist with application of LED Light pads as necessary. *

I hereby certify this form has been fully explained to me and that I am satisfied that I understand it’s meaning and significance. *

List Current Injuries / Circumstances *

Any replacement joints or other foreign bodies? If yes, please list. *

List Replacement Joints or other foreign bodies. *

Are you currently being treated for an active cancer? *

Are there any medical issues that I need to be aware of? *

List any Medical issues, not listed above. *

By selecting Yes and Submitting this form, All answers are true to the best of my knowledge. *

Informed Consent Agreement

This consent is in compliance with 2013 Colorado Senate Bill 13-215. As a Complimentary and Alternative Health Care Practitioner, I am not licensed, certified or registered by the state of Colorado as a health care professional. Colorado does not license Quantum Connections llc or any services provided by Quantum Connections llc and Leslie Schroer.
I am not a licensed medical physician and do not diagnose, treat or prescribe remedies for the treatment of disease. The services I perform, whether in person, by mail or by phone, are at all times restricted to complementary and alternative wellness services intended for the maintenance of the best possible state of well-being.
I am prohibited from; performing surgery or any invasive procedure; administering or prescribing x-ray radiation; prescribing prescription drugs; using general or spinal anesthetics; administering ionizing radioactive substances; using a laser device that punctures the skin; performing enemas/colonics unless board certified; practicing midwifery; practicing psychotherapy; performing spinal manipulation; practicing optometry; directly administering medical protocols to a pregnant woman or a person who has cancer; practicing dentistry; setting fractures; practicing massage therapy; and providing a conventional disease diagnosis or recommending the discontinuation of a course of care recommended by a health care professional. I am also prohibited from treating children less than two years of age. In order to treat a child who is between 2-8 years of age, I must have a written, signed consent of the child’s parent or legal guardian.

Check the boxes below to acknowledge that I have read and understand all parts of this consent form and I had the opportunity to ask questions with regard to the described procedures, and I hereby affirm: I am not here for medical diagnostic or treatment procedures and I am here on this and any subsequent visit solely on my own behalf. *

The services provided by Quantum Connections are as follows: The application and practice of Foot Zoning, LED Harmonic Light Sessions, Ion Detox Foot Soak, and Quantum Energetics Structured Therapy and use of applied kinesiology, (muscle testing). No promises or claims are made other than I will do my best, as I join you in your quest for a greater quality of life. My professional degrees, experience, credentials and qualifications are as follows: A two-year course of QEST education through the Quantum Energetics Institution (QEI), completed in 2011. continued LED Harmonic Light training through Shine with Light, and Foot Zoning Certification, and continued education, through We Do Feet Seminars in 2018. Please keep the lines of communication open and inform me of other care you are receiving so that we may work cooperatively. I respect the practice of other professionals and should the need arise I expect you will seek appropriate medical support. You are expected to maintain time and financial responsibilities. If you cannot keep an appointment, please call or text me 24 hours prior to your scheduled session. When possible please avoid strong fragrances, (perfumes, chemicals, cigarette smoke), which may cause sensitivities and reactions to your practitioner and clients before and after your session. If you have sensitivities, please advise me prior to your appointment.

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