Release of Liability Form

Please fill out the following form
in order to receive our services.

First Name

Last Name

Email

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Initials

I declare my awareness and acceptance: That the information I have provided in the attached form is accurate and complete. That Metaphysical Healing is not intended to replace orthodox medicine, but rather to complement it. If symptoms persist or the ailment is severe, I will consult a Medical Doctor in a timely manner. That Astrology points only toward potentials. It is up to me to use my discernment regarding the information that I receive. That I hereby release Quintile Astromancy, it's owner/operator Jacob Miller DBA Tully Astromancer, as well as any and all affiliates, venues, connected organizations and persons, from all legal recourse that may arise from the information and services provided.

Thanks for submitting!