Create Yourself
Client Information Form
Ivan Rados, P.O. Box 56581, Burnaby, V3J 7W2, British Columbia, Canada
Tel/Fax: 1+ … 604-936-7204 - 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.
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YANTRAS
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GALLERY
Sacred Geometry Yantras
