Client Information Form
Ivan Rados, #616-402 West Pender Street, Vancouver, B.C., V6B 1T6, Canada
info@ivanrados.com
Client Information Form
All client information is strictly confidential and secure.
Please fill this out completely, and Mail, Fax or email to NC Address listed above. Thank you
CLIENT NAME:_________________________________________________________________________
(last name first) first middle nickname
PARENT’S NAME:_______________________________________________________________________
CLIENT BIRTH DATE:__________________ TIME:_________________ PLACE: _____________________
OCCUPATION:______________________________________ Please include CLIENT PHOTO: ____________
HOME ADDRESS:________________________________________________________________________
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HOME PHONE:___________________________ EMAIL HM: _____________________________________
HOME PHONE 2:_________________________ CELL:___________________________________________
OFFICE PHONE:_________________________ EMAIL OFF:______________________________________
When is a good time to call schedule your appointment? ________________________________________
IS Email communication easy for you? ______________________________________________________
What are convenient times for you to have an appointment? _____________________________________
Time-Zone Converter for Pacific Time (Us & Canada) appointment
What issues do you want healed or addressed?
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Who are your Medical / Alternative providers?
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What Alternative treatments are you currently working with?
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What Medicines or Herbs are you currently taking?
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Additional Comments about things that you would like me to know that you feel would
be helpful information in assessing your issues and facilitating your healing journey.
