CHILD HEALTH HISTORY

Barbara Coon, LMT, Heartworks Healing Arts, Inc.
Office Address:
 12036 Phinney Ave N, Seattle, WA 98133  
P:
 206-391-4222 F: 206-556-2177 Tax ID: 91-1681493

 

Parent's Name *
Parent's Name
Child's Name *
Child's Name
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Would You Like To Receive My Newsletter? *
Address *
Address
Phone # of Emergency Contact *
Phone # of Emergency Contact
Describe your child's health from birth to present:
Health & Wellness
Please check any that apply to your child:
Digestion
Early Childhood Issues
Ear Issues
Jaw & Mouth
Head & Neck
Nervous System
I hereby authorize Barbara Coon LMP, Heartworks Healing Arts Inc. to perform the following specific procedures as neccessary to facilitate my child's diagnosis and treatment: Craniosacral Therapy *
I recognize the potential risks and benefits of these proecedures as described below. Potential benefits: Enhance your physical & emotional vitality, relieve pain, balance the nervous system, structural alignment, accelerate healing, provide drug free support and promote well being: *
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Barbara Coon LMP, Heartworks Healing Arts Inc. regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. *
I understand that a record will be kept of the health services provided for my child. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or unless it is required by law. I understand that I may look at my medical record at any time and can request a copy of it. I understand that my medical record will be kept for a minimum of three, but no more than seven years after the date of my last visit. I understand that information from my medical record may be analyzed for teaching purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by Barbara Coon LMP, Heartworks Healing Arts Inc. to the best of her ability. I understand my medical records are private and confidential according to HIPAA and may only be shared by my request. *
In Fairness to all, I will give a 24-hour notice of cancellation. If you cancel less than 24-hours before your scheduled appointment you will be charged the full cost of the treatment. *
Date *
Date