Sound Bath Consent & Intake Form
Facilitator: Arlene Kamalatisit Los Angeles, CA
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact (optional)
How did you hear about us?
Health Information (Confidential)
Heart condition / pacemaker
Epilepsy or seizures
Hearing sensitivities or conditions (e.g., tinnitus)
Pregnancy
Recent surgery or injury
Metal implants
Anxiety or PTSD
Vertigo or balance issues
Other (please specify)
If other health conditions, please specify:
Are you currently under medical treatment or taking medication?
*
Yes
No
If yes, please describe
Consent & Acknowledgment
*
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Facilitator Signature
*
Date
*
-
Month
-
Day
Year
Date
Optional Media Consent
I give permission for photos or short video clips (with my consent at the time) to be used for social media or promotional purposes.
I prefer not to have any photos or recordings taken.
Client Initials
Submit
Submit
Should be Empty: