Informed Consent For Frequency
Demo, Therapy, Training
Independent OlyLife Distributor Name: Christa M. Emrick 210-710-4793
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.