Intake Form

To make an appointment for an intuitive medical scan and phone consult with Susan, please fill out this form (being sure to leave nothing blank) and send. Each family member or pet needs a separate intake form.

First and last name:
Email:		A value is required.Invalid format.Invalid format.A value is required.
Date of birth:
Age:
Telephone:
Cell:
Street Address:
Enter the street address above to which credit card statements are mailed.
City:
State or Province:		Invalid format.
Zip or Postal Code:		Country:

Occupation:
Referred by:
List your present diagnoses/symptoms:
Present healing modalities
Herbs?		yes no
Homeopathy?		yes no
Acupuncture?		yes no
Energy healing?		yes no
Do you see an MD for any condition?		yes no
If yes, what condition/s?
List any medications you are taking now:

Preferred appt. days:		Monday Tuesday Wednesday Thursday Friday
Preferred appt. times:		(Pacific Time)
Please make a selection.		I have read the FAQs on Susan's web site.
Please make a selection.		I have read and agree to the charges for these services.
Please make a selection.		As a prospective client, I understand that medical intuition is not a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. If disease names are used in the course of treatment, it is understood that these names describe frequencies commonly associated with disease, but are in no way proven to be the actual diseases themselves. Diagnosis of disease requires laboratory tests and other diagnostic procedures which are not part of medical intuition or energetic therapy.