Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have any difficulty lying on your front or back? *

Yes

No

Health History *

Fatigue/Sleep Disorder

Cancer

Psychiatric Disorder

Numbness/Tingling

Sinus Problems

Rashes

Heart Condition

Jaw Pain/TMJ

Diabetes

Gas/Bloating

Broken/Fractured Bones

Pregnancy

Herpes/Shingles

Allergies

Varicose Veins

Tinnitus

Blood Clots

Headaches

Sprains/Strains

High Blood Pressure

Low Blood Pressure

Chronic Pain

Constipation

Arthritis

Depression/Anxiety

Spasms/Cramps

Other (explain below)

What are your goals with Sound Therapy? *

Relaxation

Pain Relief

Stress Reduction

Insomnia

Journeying

Astral Projection

Increase Energy

All of the above and more!

Do you have any sesitivity to sound or vibration? *

Yes

No

It is my choice to receive Vibrational Sound Therapy and I understand that the practitioner will be using gentle 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 practitioners certified by the Vibrational Sound Association 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 primary health care provider I am receiving these sessions and inquiring as to whether or not they may adversely affect my current health condition. *

YES, I understand.

NO, I do not want Sound Therapy.

I understand that Vibrational Sound Therapy is a gentle, sound-based approach to health and healing that can potentially assist my body in its natural ability to heal. I fully acknowledge and understand that this may be accomplished through the use of light contact and/or no contact touch. I acknowledge that long term imbalances or dis-ease in my body sometimes requires multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. I understand that Vibrational Sound Therapy is not intended to replace any currently prescribed medical treatments as ordered by my physicians, nor any other medical care I have, or may be advised to seek by them. I understand that the practitioner will neither diagnose any medical condition, nor prescribe for any condition that I might have, nor does that practitioner make any specific claims regarding results from the sessions that I receive. I agree that it is my responsibility to consult a licensed medical practitioner for any physical or mental complaints I may have. I understand that all client information and records are treated in a confidential manner. My experiences during these sessions are confidential subject to the usual exceptions governed by state or federal laws and regulations. I, or my representative(s) agree to fully release and hold harmless One Song Sound Medicine and practitioners therein from and against any and all claims or liability of whatsoever kind or nature arising out of, or in connection with, my session (s). *

YES, I consent and want to receive Vibrational Sound Therapy.

NO, I do not consent and do not want to receive Vibrational Sound Therapy.