SOUND THERAPY

SOUND THERAPY

INTAKE FORM
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Occupation*
Emergency Contact*
Name and Phone / Mobile:
Health Information:
Doctor's Name and Contact:*
List of Medications and what is it for:
Health Problems *
(Current and History)
Do you have any electronic implants (e.g: pacemaker, cochlear)?*
Do you suffer from any mental illnesses*
Are you pregnant?*
How many weeks
Do you suffer from epilepsy or seizures?*
Have you recently had a heart attack, stroke or any surgery?*
DECLARATION:

I fully aware that the services I wish to receive are those of a holistic nature and do not serves as a substitute for professional medical advice, examination, diagnosis or treatment.

I will immediately inform my practitioner of any changes to my conditions and medical status.

I understand the information I have given to be the truth.

I understand that Sound Therapy is not suitable for epilepsy, seizures, first trimester of pregnancy, recently had a heart attack, stroke and surgery, electric implants.

I must inform the practitioner minimum 48 hours, if i need to change or cancel the appointment, otherwise 50% fee will be applied.

I understand the practitioner does not claim to cure or diagnosis any medical condition in the same way as a doctor/physician. Their opinion is that of a holistic, complimentary and alternative therapist and their professional opinions, advice, examinations and recommendations do NOT constitute the medical advice of a docotor/physician.
Signature*

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SOUND THERAPY

Health Information: