New client forms

Please click on a file to enter your information

Your current state of health?

Do you have any areas of physical discomfort? If so, please describe the location.

What brings you joy?

The most emotionally draining relationship in your life:

Is your home environment peaceful or stressful most of the time?

Do you have trouble concentrating, or ‘brain fog’?

Yes No

Do you feel supported?

Yes No

Please check the emotions that best reflect how you feel most of the time:

Do you adhere to a particular diet?

On average, how many hours of sleep do you get per night?

Are you sensitive to light/loud noise?

Yes No

If yes, please explain

Regaining well being requires a strong personal commitment. How ready are you to make any necessary changes ?

Ready Somewhat Not interested in making changes

I have read the above information and have filled out the form to the best of my knowledge. I understand that the questions on this form are being asked in order to better access my current circumstances and their relationship to my well-being. I further understand that I am voluntarily agreeing to have a relaxation session and that no medical claims or promises of healing have been given.

INFORMED CONSENT/CLIENT DECLARATION

I hereby voluntarily consent to a relaxation session at Harmonic Life. I understand that it may be necessary to have more that one session, to receive maximum benefit.

I am responsible for the decision to seek this type of relaxation program that could include improvement of the physical, psychological / emotional and environmental aspects of my l life. I recognize that the Harmonic Life staff do not treat any specific disease or illness and they are not licensed, certified, or registered by the state as health care professionals. However, all staff members possess the proper training and certifications to administer sessions for clients. I recognize the possibility that this program may not prove successful or accomplish the results I expect or hope for. I understand that in most cases best results are obtained with a multi-session program / protocol.

I am fully informed that this approach to health differs from, and may not be recognized by, traditional medical standards. I hereby waive any claims and demands that I might now or hereafter have against Harmonic Life or its owners or staff that may arise, or deemed to arise from participating in sessions at Harmonic Life, and I hereby further release Harmonic Life and its owners and consultants from any and all liability of whatsoever kind or nature arising out of or in any way relating to the sessions I will receive at Harmonic Life. Harmonic Life does carry liability insurance as deemed necessary by the State of Texas and the leasing agent in which we are doing business on their property.

I understand that Harmonic Life reserves the right to deny treatment if it is not deemed by Harmonic Life to be in the best interest of the client(s) or staff.

It is understood that any sessions, or modalities are intended to enhance overall body performance and are not intended or implied to treat or “cure any specific illness.” It is understood that any suggestions are only Harmonic Life’s best recommendation and are at no time to be considered a prescription.

Electronic Signatures: For purposes of this Agreement, the use of facsimile, email or other electronic medium shall have the same force and effect as original signatures.

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Disclaimer : The statements made or services provided through this website or by the Company are not intended to diagnose, treat, cure or prevent any disease. Testimonials regarding the technology are voluntarily given and do not represent the opinions of Harmonic Life. The services provided by the Harmonic Life are not intended to be a substitute for professional medical advice, diagnosis, or treatment.

1919 S Shiloh Rd. Suite 546, Garland, TX 75042, Phone: (972) 215-776

New client forms

INFORMED CONSENT/CLIENT DECLARATION

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