Intuitive Scan Intake Form After first setting an appt. time with Susan, and then making payment for services, fill out this form. Please be sure to complete all fields and send. Each family member or pet needs a separate intake form. *All fields are required. *First Name *Last Name *Your Email *Date of birth *Age *Phone number *Is this number a land line or cell line? landcell Optional second phone number Is this number a land line or cell line? landcell *Street address *City *State *Zip or Postal code *Occupation *Referred by *List your present diagnoses/symptoms and any past significant illnesses/accidents. *Present healing modalities HerbsHomeopathyAcupunctureEnergy healingNone *Do you see a medical doctor for any condition? yesno *If yes, what conditions? *List any medications you are taking *I have read the FAQs on Susan's website *I have read and agree to the investment for these services. *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.