BIOUSOUND REGISTRATION/CONSENT FORM

How did you hear about us?*

Full Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Number*

Email Address*

example@example.com

Preferred contact method:

TextCallEmail

Emergency Contact *

First and Last nameRelationship

Phone Number*

Please enter a valid phone number.

Check the symptoms that you' re currently experiencing:*

Are you Pregnant*

YesNoOther/ does not apply

Have you ever had a blood clot (Thrombosis)?*

YesNoNot Sure

Do you have metal implants(s), a defibrillator, or pacemaker?*

Metal Implant(s)DefibrillatorPacemakerNone

Do you have a seizure disorder?*

YesNo

Have you ever been diagnosed with Schizophrenia?*

YesNo

Have you had a recent head trauma?*

YesNo

Biosound® Therapy is not intended to be a substitute for any diagnosis, or to be a used as an alternative to necessary physical or mental health care. I understand Biosound® Therapy my be discontinued at any time, by either party. I understand that I must inform, and continue to fully inform, my Biosound® Tech of any medical history changes.

I understand that, as with all health care approaches, results are not guaranteed, and there is no promise to cure. I understand that information about my session may be used for research purposes, but no protected health information will ever be disclosed.

I understand sessions may include, but are not limited to: Biofeedback, guided imagery, meditation, cell massage, music therapy, and video affirmation content. I accept it is not possible to consider every possible complication of care. I understand that Biosound® Therapy can have precautions, though uncommon. I understand this agency's liability is limited to fee-for-service, and, in n event, will the agency be liable for any damages. I have been informed Biosound® Theeapy is a generally safe method of treatment, and as with all types of therapeutic interventions, there are risks.

(Precautions) For Biosound Massage.

Out of an abundance of caution, a waiver will be completed for some individuals, including those who report: Pregnancy, Thrombosis, Recent Head Trauma, Pacemaker or Defibrillator, Seizure and/or Schizophrenia.

Seizure Disorders and Schizophrenia are always contraindicated. A waiver is recommended for those with a pacemaker/defibrillator, as the Biosound® bed contains magnets. Contraindications for vibroacuoustics are relative, meaning there is a higher risk of complications; however, these risks may be outweighed by the other considerations, or mitigated by other measures. Relative contraindications are sometimes referred to as cautions.

Please check below indicating you have read Consent To Treatment

Terms and conditions: My signature below means I accept and fully understand the above questions have answered them honestly; have read, reviewed, and initialed Consent To Treatment; and give my consent to receive this treatment. I agree to use electronic records and signatures.

Signature*

Biosound Registration / Consent Form

After you submit the form, you’ll be able to select a session and schedule your appointment.

After you submit the form, you’ll be able to select a session and schedule your appointment. See you soon!