Client Release and Contract
   on   November 13, 2012             Page 1 of 2
                                  
Please fill required spaces marked with the red X
                                                         between  B Brent Atwater

     X  _____________________________________________________________________("Client") of
            Please print Name    
     X  ______________________________________________________________________
Address
     I understand that B Brent Atwater is an intuitive consultant and does not present herself as possessing
  any formal training nor as a licensed, registered or certified practitioner or counselor.
     In consideration
of the promises and conditions contained herein, I seek and it is my intent to hire
  Ms. Atwater for Intuitive Consultation(s). As further consideration for
  Ms. Atwater's Services, I agree to provide certain current, complete and accurate information
  about myself as required on Ms. Atwater's client information form.
  No one representing Ms. Atwater or Ms. Atwater offers me any false hope, false promises,
  expectations, warranties, or assurances of the success or the outcome of any of
  Ms. Atwater's work. 
    I have read and understand Ms. Atwater's are pre paid BEFORE my appointment is scheduled,
  and non refundable.  I agree to the payment terms and conditions and to pay the total fee amounts
  for Ms. Atwater's services in US Funds. I choose the following service (s). Please write clearly

       1. _______________________________________________                Fee:________________ X
                                                                   
       2. ________________________________________________              Fee:_________________
                                                                   
       Additional Fees if applicable: Emergency : _______________            Travel:________________
                                                                                     
                                                                                   Initial Total fees are: __
_______________ X

    
 If I pay by debit or credit card , I understand that by providing the following information to Ms. Atwater,
  and Energy Work, Inc., that I agree to and I legally authorize that the debit or credit card below be
  charged to pay for Ms. Atwater's Services. I agree to pay for the any fees if my card is declined.
    If I pay via PayPal, I agree to and authorized that transaction to pay for Ms. Atwater's services. 
 
The PayPal email address is Brent@BrentAtwater.com.   
    I understand and agree to the following:
 a. If I need to reschedule my appointment, that I am required
  to give Ms. Atwater's office a 24 hour notice.  b. If I miss my appointment, without giving Ms. Atwater's
  office a 24 hour notice for rescheduling, I will be charged the full fee for
Consultations and or Energy
  medicine and or Travel arrangements
.  c. I phone Ms. Atwater for my sessions and pay
  the charges.

    I
am eighteen (18) years of age or older, of sound mind, and not under any mind altering drugs.
  By signing this agreement, I acknowledge that I have read the above, have thoroughly reviewed and
  understand its contents, and that I am giving my informed consent and it is my intent to agree to this
  contract. By my written acceptance of this agreement, I know this document becomes a legally binding
  contract and is confidential. 
This Contract shall be governed by and construed in accordance with the
  laws of the State of North Carolina
.

  X  Signature:________________________________________Seal    Date: ___________________  X
   
      Witness: ___________________________________________

      Consent by Legal guardian, Parent or Attorney in Fact.
   As the Parent and or Legal Guardian, or POA,
 I acknowledge that I have read the above, have
   thoroughly reviewed and understand its contents, and that I am giving my informed consent. It is my
   intent to agree to this contract. 

   I authorize you to provide services for: ___________________________________ ( Client).

   X  Signature:______________________________________Seal    Date: ___________________  X

      Witness: ________________________________________



 


                                                            
                                         PO Box 475    Southern Pines, NC 28388 USA
          
                                            Email: Brent@BrentAtwater.com                                            
                                                             
                                 C
lient Release and Contract  on November 13, 2012     page: 2 of  2
                                  Be sure to fill in the required spaces marked with the red X

            My payment method for my appointment(s) is: Please check one of the following

                   Personal Check:__________     Money Order:_________   Pay Pal:_____________

                   Credit or Debit Card:________   Type of card:_________________________________

          
X Name as it appears on the card:______________________________________________

          
X Card number, Please Print CLEARLY:_________________________________________

          
X Expiration date of card :____________________________

          
X The last three numbers on  signature strip:_____________



           The Billing Name and Address as it appears on the card's statements:

         
  X  _______________________________________________________________________

          
 X _______________________________________________________________________
 
         
  X _______________________________________________________________________

          
 X  _______________________________________________________________________ 
                                    
            You will receive instructions for your appointment(s) when it is scheduled.  Thank you.