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Hopi Ear Candle Client Consultation Form
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Caution Check (please check all applicable):
Do You/Have you suffer(ed) from Any of the Following:
Is the left ear, right ear or both ears affected?
Which is Ear Worst?
Are Any of the Following Currently Applicable?
Are you allergic to Any of the Following (these are the ingredients of the candles)?
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Have you received your Covid-19 vaccinations?
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Thank you for submitting.

You will be presented with a hard copy for your signature at your appointment.