What Service Did You Book At Nibana?
When Will Your Service Be?
Please Provide Date & Time
Please Name Other People Who Are Coming With You:
Parent or Legal Guardians Full Name in the case of a minor under the age of 18yrs
Please add your phone number if you are the Adult Client, Parent or Legal Guardian of a minor
Please add your email address if you are the Adult Client, Parent or Legal Guardian of a minor
Please type the date of birth of the person who will be having a healing session, class or other as follows: month/day/year
Please add your address if you are the Adult Client, Parent or Legal Guardian of a minor
Emergency Contact Person's Full Name*
Emergency Contact Person's Phone #*
Emergency Contact Relationship*
Do you suffer from any Disease or Illness?*
Please type in NO if you do not | Please type YES and explain if you do:
How did you hear about us?*
Website | Road Sign | Flyer | Friend, Family | Recommendation | Other?
By checking here, you are consenting and are in agreement that this be your electronic signature in lieu of a signature on paper and you confirm that:*
Thank you for completing and submitting your Service Intake Waiver Form, we appreciate you taking time to do this. We will be in touch shortly. In the meantime please receive much Love n'Light We look forward to seeing you soon!