Pain Management In-Take Form Please note that all fields are required. Your Full Name Your Email Address Your Phone Number Your Birth Date Marital Status Occupation What do you wish to accomplish in this/these session(s)? Please provide more information if you have made previous efforts to make this change. Please provide more information if you have ever been treated for an emotional problem. Any additional information you want to add or I should know? 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.