The Client History Form

FORM SAVE AND RETURN ACCOUNT IS AN OPTION

DO NOT USE YOUR QT STORE ACCOUNT HERE! You may save your progress and complete this form at a later time, if desired. You may also complete the form NOW without generating a password. Without a "save and return password" for this form, you will NOT be able to return and complete if unfinished.

Thank you for choosing to provide additional information about your health history and lifestyle - this will make the first session with your practitioner flow more smoothly and be less costly!

For TECHNICAL SUPPORT or to submit this form by telephone, contact Cheyene Stone:

Office: U.S. 855-QT Heals (784-3257) | World 1-786-567-8663 | Email: support@quantumtechniques.com

If you have questions on anything related to this process call the QT Office Manager, Cheryl DeMauro, at 928-771-1215 or 888-767-8002.

Quantum Techniques New Client History Form

Contact Information

First Name *

Last Name *

Email Address *

(Email information is used for monthly statements only.)

Telephone Number: *

Preferred Practitioner: *

Dr. Stephen P. Daniel, Ph.D, FPPR	Beth Daniel, M.A., Ed.S.
Jody King Colegrove, ACP-EFT	Dr. Carolee Johnson N.D., M.H.
Dr. Thomas Miller	Dr. David Kirkpatrick
---(KK)	JJ Curren
Other Other