Tamara Shadday, C.Ht.
727-452-5630
PLEASE RETURN SIGNED FORM TO:
Tamara Shadday C.Ht.
www. hypnosisstpetersburg.com
Fax: 727-213-6900
 
I am aware of my above referenced patient's desire to use hypnosis to help
With his/her below listed symptoms and/or to promote wellness and have no
objection.
 
My patient has the following diagnoses:
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Additional Comments or instructions:
________________________________________
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Physician's Signature: ______________________________ Date: ________________
Printed Name: ____________________________________ Phone: _______________
Address: ______________________________________________________________
 
Dear Dr. __________________________
 
I am interested in obtaining hypnosis from:
 
Tamara Shadday, Certified Hypnotist
727-452-5630
FloridaHypnotherapy.com
 
To help relieve the following symptoms, problems or conditions:
______________________________________________________________________
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My hypnotist requires this form prior to my first appointment on:
indicating that my health care professional is aware of my desire to
use hypnosis and to avoid masking any symptoms before a proper medical diagnosis has been
made and/or necessary medical treatment administered.

 
Patient/Client Signature: __________________________________________________