Devachanna Intake Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Email *Phone NumberBirthdayMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Understanding *I, (please enter name above), understand that as a client, any sessions I receive for any of Devachanna Company services by practitioner, Laura Kellogg are for the purpose of healing and strengthening my physical, mental, emotional or spiritual self. I understand that Laura Kellogg does not diagnose illness, disease or any other physical or mental disorders. I understand that sound healings provided are not a substitute for medical treatment and that it is recommended that I see a physician for any physical ailment(s) when and where appropriate at the discretion of me as the client. I understand that all discussion during any appointments are held in confidence between myself and Devachanna. I have stated any known medical condition(s) & take it upon myself to keep the practitioner updated on changes in my physical health. Therefore, except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Laura Kellogg from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).SignatureClear SignaturePhoneSubmit