NAME *

First Name

Last Name

ADDRESS *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PHONE *

(###)

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TIME *

Best time to call Monday thru Friday, 10am to 7pm (EST) to set your appointment(s)

Hour

Minute

Second

AM PM

METHOD / FREQUENCY preferred *

In-Person

Remote

Single Session - $95

Buy 5, Get one FREE - $475

CONDITIONS we should know about

Check all that may apply

Pregnancy

Allergies

Recent illness / injury / surgery

Limitations

Medications

Mental health

Other

•ALL SERVICES are paid in full prior to their start or appointment date(s) and are non-refundable. I will provide 24-hour notice to cancel or reschedule. In group settings, I will respect the space of others and ensure that anything shared by other participants in feedback remains confidential. Any disruptive or offensive behavior/comments will see me removed. I understand that alcohol, smoking/vaping, and illicit drugs are NOT permitted at The Purple Tulip, and their use are strongly discouraged just prior to and just after when services are provided. It is my responsibility to share any restrictions or concerns that may require alternative arrangements. The healing modalities offered by The Purple Tulip are supplemental and are not a replacement for directives given by a licensed medical provider or mental health professional. If I have any concerns, it is my responsibility to inquire and/or contact my health care professional. Long-term imbalances may require multiple sessions / classes / workshops for my body, mind, or spirit to heal itself. I affirm that I am mentally, emotionally, and physically fit to participate. •THE PURPLE TULIP LLC is not responsible for any errors or omissions, or for the results obtained from the use of ANY of the services offered. The Purple Tulip reserves the right to revise or cancel offers at any time without notice. All policies and practices may be subject to change as needed or required. •CHAKRADANCE™ is a trademarked company and a copyrighted program which The Purple Tulip LLC is licensed to run. •ALL MATERIALS provided by The Purple Tulip LLC are copyrighted and may not be altered, sold, or shared. Materials are for individual use only and may NOT be reproduced with the intent of distribution. *

Electronic Signature

I affirm the information I have provided is correct and I agree to these terms and conditions.