The Client History Form

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 Support please contact us at:

Office: 928-771-1215 | Email:cheryl@quantumtechniques.com

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

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 Support please contact us at:

Office: 928-771-1215 | Email:cheryl@quantumtechniques.com

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

FORM SAVE AND RETURN ACCOUNT IS AN OPTION

DO NOT USE QT STORE ACCOUNTS 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.

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: *

Returning Client? *

Yes

No

Dr. Stephen P. Daniel, Ph.D, FPPR	Jody King Colegrove, ACP-EFT
TM (office use only)	Dr. David Kirkpatrick
JJ Curren	Jamie Daniel-Delgado
Other	BD (office use only)
(Admin Use-CJ)	KK (office use only) KK (office use only)