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Informed Consent For Frequency
Demo, Therapy, Training

Independent OlyLife Distributor Name:  Christa M. Emrick    210-710-4793

​                                      Christa@olylifeglobal.com 

Client Full Name:___________________________________________________________

 

Birth Date:_________________________Phone:_________________________________

 

Email:____________________________________________________________________

 

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Please answer the following questions: 

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Do you have a pacemaker or any type of implanted device?  YES______ NO______

 

Can you turn off your implanted device? YES____ NO_____ 

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Are you pregnant?  YES______ NO______

 

Do you suffer from a Hemorrhagic Disease? YES_____ NO_____

 

Warning!

Implants must be turned OFF before use. It is my responsibility to avoid any contraindications and, if I have an implanted device, it is my responsibility to turn it OFF before use. If your implant can not be turned off, you can NOT use this device.

CLIENT CONFIDENTIALITY 

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I,___________________________________, understand any information provided to the Independent OlyLife Distributor is confidential and will not be shared with anyone, EXCEPT when specifically required by law or when I give written permission on a separate document. I have the right to withdraw this permission at any time. 

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DISCLAIMER 

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I understand that the Independent OlyLife Distributor cannot diagnose, cure or treat, those issues, diseases, disorders, or conditions and will not go outside of her scope of practice. I understand that frequency Therapy/Training may be an adjunct or complement, not a substitute, for medical or psychological treatment; and any ongoing medical treatment should not be discontinued without the advice of my treating physician. 

CLIENT AGREEMENT 

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I consent to receive Frequency Therapy/Training from the Independent OlyLife Distributor. I understand my health and wellness is my responsibility. Therefore, I agree to use the services offered by the Independent OlyLife Distributor to help me learn how to manage my health and wellness better. I further understand that I can discontinue Frequency Therapy/Training at any time and may decline any particular Frequency Therapy/Training at my sole discretion. 

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Furthermore, I understand that I accept any liability for my experience with frequency technology, and I may work with a professional or consultant for more feedback and education only. I understand that my actions are my responsibility, and it is also my own responsibility to avoid any possible contraindications. 

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I also understand that it is my responsibility to avoid any contraindications and, if I have an implanted device, it is my responsibility to turn it OFF before use. 

By signing below, I acknowledge I have read and understand this document, and I have received acceptable answers to my questions about Frequency services from the Independent OlyLife Distributor.

CONSENT 

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My signature below indicates that I have read and understand the information in this document and that I consent to Frequency therapy under the provisions stated. If I do not understand or consent to anything stated in this document, it is my responsibility to request and receive clarification before signing below. 

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Client Signature____________________________________________Date_______________

 

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IF CLIENT IS A MINOR, PARENT/GUARDIAN MUST SIGN BELOW 

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I attest that I have the full legal authority to make decisions for the minor named above and that I give my permission for him/her to undergo Frequency Therapy/Training. 

Parent/Guardian.

 

Signature________________________________________Date_______________ 

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Minor’s Name:_____________________ 

Please download and bring with you for your next appointment.

©2025 Proudly created by Christa M. Emrick with Wix.com for Alchemy Massage & Bodywork, SA

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