Client Information

Full Name

Email

Phone

Wellness Goals

Main goals or concerns

Current products, herbs, or supplements you want Blaque Sol to know about

Services Requested

30 Minute Consultation — $150
Face Mapping Assessment — $120
Hair & Scalp Mapping — $120
Tongue Assessment — $120
Teeth Mapping Assessment — $120
Lip Assessment — $120
Astrology & Natal Chart — $185
Cartomancy Assessment — $198
Mineral Assessment — $150
Herbal Wellness Plan — $85
Personalized Protocol — $120
Follow-Up Visit of 30 Minutes — $75

Required Agreement

I agree that the information I submit is accurate.

I understand Blaque Sol provides private wellness education and support, not emergency care or licensed medical treatment.

I understand I should speak with my licensed provider before making changes to medications, treatment plans, herbs, supplements, or lifestyle practices.

I agree to the selected service price, payment, cancellation, deposit, and rescheduling terms.

Typed Client Signature

Date