FORM MUST BE SIGNED BY ALL PARTICIPANTS. IF PARTICIPANT IS UNDER 18 YEARS OF AGE, FORM MUST BE SIGNED BY MINOR AND HIS/HER PARENT/GUARDIAN.

I hereby request and consent to the performance of Sound Therapy and/or Reiki treatments and other procedures within the scope of practice of energy work on me (or on the client named below, for whom I am legally responsible) by Shawna Bass and/or other energy practitioners who now or in the future treat me while employed by, working or associated with RESTORE Wellness.
I understand that methods of treatment may include, but are not limited to: Reiki light touch, acupressure using tuning forks, singing bowls used on and around the body, reflexology, aromatherapy, smudging using white sage and toning counseling. I understand that the smudging involves burning of the white sage and the resulting smoke is used to clear negative energy but is not mandatory and I have the right to refuse smudging. I will immediately notify the practitioner of any unanticipated or unpleasant effects associated with smudging.
I have been informed that acupressure is a generally safe method of treatment, but that it may have some side effects including: bruising, tingling near the pressure sites that may last a few days and dizziness or fainting.
I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the practitioner to exercise judgment during the course of treatment which the practitioner thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed.
I understand the practitioner may review my client records, but all my records will be kept confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of Sound Therapy, acupressure and other procedures, and have had an opportunity to ask questions. I understand that the practitioner does not diagnose illness, disease, or physical or mental disorders, nor prescribe medical treatments or pharmaceuticals. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that it 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 treatments and inquiring as to whether or not they may adversely affect my current health condition.
I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

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* 1. Name (First, Last)- If minor, please include name and age of minor receiving treatment along with full name of parent/legal guardian.

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* 2. Date Signed

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