Informed Consent For Frequency
Demo, Therapy, Training
Independent OlyLife Distributor Name: Christa M. Emrick 210 - 710 - 4793
Client Full Name:___________________________________________________________
Birth Date:_________________________Phone:_________________________________
Email:____________________________________________________________________
Please answer the following questions:
Do you have a pacemaker or any type of implanted device? YES______ NO______
Can you turn off your implanted device? YES____ NO_____
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
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.
DISCLAIMER
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
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.
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.
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
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.
Client Signature____________________________________________Date_______________
IF CLIENT IS A MINOR, PARENT/GUARDIAN MUST SIGN BELOW
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_______________
Minor’s Name:_____________________
Please download and bring with you for your next appointment.