Pain Management In-Take Form

Please note that all fields are required.

By submitting this form you agree to the information below.

I realize that Jaco Pieterse is a hypnotist and not a medical doctor or psychologist, and that he cannot diagnose disease, prescribe, or treat medical conditions or serious disorders. I understand that the session(s) I am receiving from Jaco Pieterse is not a substitute for normal medical care and I have been advised to discuss this procedure with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular physician for treatment of any new or old illnesses. I also agree that Jaco Pieterse or myself may terminate this relationship at any time for any reason whatever.