Consent Form

Name:

Email:

Tel No:

Emergency Contact   (Name & Tel No.):

Are you over 16 years old?

YesNo

Have you recently had any surgery or any medical procedure?

YesNo

Do you have any serious medical condition or general special need?

YesNo

Are you being treated for, or do you currently have: Clinical depression, bipolar disorder, schizophrenia, paranoid schizophrenia or any other serious mental health condition?

YesNo

Are you less than 3 months pregnant?

YesNo

Do you have or have had frequency triggered epilepsy or any seizures which you believe is sound triggered?

YesNo

Do you have metal implants, plates or other metallic items in your body?

YesNo

Declaration   (Please tick to accept)

It is my choice to receive Vibrational Sound Therapy, and I understand that the practitioner will be using sound and vibration during the sessions on/around me. I have completed this form to the best of my knowledge. I have stated all medical conditions that I am aware of, and I will update my practitioner of any changes to my health status. I understand that sound practitioners do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments or pharmaceuticals. I acknowledge that these sessions are not a substitute for medical examination or diagnosis, and that is recommended I see a primary health care provider for those services. I understand that I alone am responsible for informing my doctor I am receiving these sessions and inquiring as to whether or not they may adversely affect my current health condition.

Date: