~~~~~~~ CLIENT DATA RESEARCH APPLICATION ~~~~~~~
IF YOU ARE ON THIS PAGE YOU HAVE DECIDED TO JOIN US IN THE MOST ADVANCED BIOACOUSTIC RESEARCH EVER. WE WOULD LIKE TO WELCOME YOU TO A GROUP OF OUTSTANDING RESEARCHERS. THE EVALUATION OF YOUR VOICE WILL CONTRIBUTE TO ADVANCEMENTS IN DETERMINING THE FREQUENCIES OF MODERN DAY PHYSICAL IMBALANCES AND ILLNESS IN THE HUMAN BODY.
~~~~~~~ THANK YOU FOR JOINING US ~~~~~~~
~ ALL ISSUES EXPRESSED IN TERMS OF FREQUENCY EQUIVALENTS ~
BIOACOUSTIC BIOLOGY RESEARCH STUDIO ASSESSMENT APPLICATION
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Fax Machine ( ) __________________________________ Best Time To Call _________________________________________
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Please list the issues or concerns that you would like to discuss during your appointment.
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Please list all medications, supplements, vitamins, and herbs you are currently taking.
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Are you allergic to any of the following? Dairy, Wheat, Grains, Soy, Dust, Grass, Trees, Pollen, Chlorine, Formaldehyde, Cosmetics, Perfumes, Detergents, Cleaners, Gas, Glue, Paint, Dye, Animal dander, Peanuts, Mold, Other _________________________________
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Do you have a history of seizures? Yes No _______________________________________________________________________
Do you smoke? Yes No If so, how many packs a day? ______________________________________________________________
Do you drink? Yes No If so, how often? __________________________________________________________________________
Do you use any street/recreational drugs? If so, what and how often? _____________________________________________________
Have You Contacted Your Local BioAcoustic Practitioner? If So Whom? ___________________________________________________
How did you hear about BioAcoustic Biology Research Studio? __________________________________________________________
SIGNATURE REQUIRED ON NEXT PAGE
Reassessment is Essential, you will need to follow up!
________Do you understand that BioAcoustic Biology Research Studio does not accept checks?
Please Initial
(Forms of payment accepted are Visa, Mastercard, Discover, American Express, Money Orders, and Debit Cards with the Visa/Mastercard logo.)
________Do you understand that full payment is due at time of services?
Please Initial
________It is very important that you show up for your appointment. We have a long waiting list. If you will be unable to keep your appointment, please allow adequate notice so that someone else can take your slot. If you cancel within 48 hours of your appointment, you may be charged a $250 cancellation fee.
Please Initial
I fully understand that an assessment with BioAcoustic Biology Research Studio is utilizing an experimental technique, that requires significant follow up including reporting any change or results that may occur. I also understand that this is an ongoing process that may not produce results with only one appointment.
_______________________________________________________ _______________________
Signature Date
_______________________________________________________
Printed Name
Home Address ________________________________________________________________________________________________
City _______________________________________________ State ________________________ Postal/Zip ____________________
Country _________________________________ Email _______________________________________________________________
Day Phone ( ) ___________________________________ Home Phone ( ) _________________________________________
Fax Machine ( ) __________________________________ Best Time To Call _________________________________________
Under Care Of (Physician) _______________________________________________________________________________________
Please list the issues or concerns that you would like to discuss during your appointment.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Please list all medications, supplements, vitamins, and herbs you are currently taking.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Are you allergic to any of the following? Dairy, Wheat, Grains, Soy, Dust, Grass, Trees, Pollen, Chlorine, Formaldehyde, Cosmetics, Perfumes, Detergents, Cleaners, Gas, Glue, Paint, Dye, Animal dander, Peanuts, Mold, Other _________________________________
_____________________________________________________________________________________________________________
Do you have a history of seizures? Yes No _______________________________________________________________________
Do you smoke? Yes No If so, how many packs a day? ______________________________________________________________
Do you drink? Yes No If so, how often? __________________________________________________________________________
Do you use any street/recreational drugs? If so, what and how often? _____________________________________________________
Have You Contacted Your Local BioAcoustic Practitioner? If So Whom? ___________________________________________________
How did you hear about BioAcoustic Biology Research Studio? __________________________________________________________
SIGNATURE REQUIRED ON NEXT PAGE
Reassessment is Essential, you will need to follow up!
________Do you understand that BioAcoustic Biology Research Studio does not accept checks?
Please Initial
(Forms of payment accepted are Visa, Mastercard, Discover, American Express, Money Orders, and Debit Cards with the Visa/Mastercard logo.)
________Do you understand that full payment is due at time of services?
Please Initial
________It is very important that you show up for your appointment. We have a long waiting list. If you will be unable to keep your appointment, please allow adequate notice so that someone else can take your slot. If you cancel within 48 hours of your appointment, you may be charged a $250 cancellation fee.
Please Initial
I fully understand that an assessment with BioAcoustic Biology Research Studio is utilizing an experimental technique, that requires significant follow up including reporting any change or results that may occur. I also understand that this is an ongoing process that may not produce results with only one appointment.
_______________________________________________________ _______________________
Signature Date
_______________________________________________________
Printed Name
~~~~~~~ FEE SCHEDULE ~~~~~~~
Assessments are $125.00 per hour.
Weekends & Holidays (if available) carry an additional $40.00 surcharge per hour.
Initial appointments span over a two day period and can last anywhere from 3-8 hours, depending on the complexity of the case.
You may need to purchase a tone box at $450.00 in order listen to your tones outside the office. The tone box is a one-time purchase which can be reprogrammed any time an adjustment is needed to listen to your tones.
FULL PAYMENT IS EXPECTED IN ADVANCE OF DELIVERY OF SERVICES AND GOODS. BIOACOUSTIC BIOLOGY RESEARCH STUDIO IS A RESEARCH ORGANIZATION, THEREFORE WE CANNOT EXTEND CREDIT NOR ACCEPT BARTER.
Assessments are $125.00 per hour.
Weekends & Holidays (if available) carry an additional $40.00 surcharge per hour.
Initial appointments span over a two day period and can last anywhere from 3-8 hours, depending on the complexity of the case.
You may need to purchase a tone box at $450.00 in order listen to your tones outside the office. The tone box is a one-time purchase which can be reprogrammed any time an adjustment is needed to listen to your tones.
FULL PAYMENT IS EXPECTED IN ADVANCE OF DELIVERY OF SERVICES AND GOODS. BIOACOUSTIC BIOLOGY RESEARCH STUDIO IS A RESEARCH ORGANIZATION, THEREFORE WE CANNOT EXTEND CREDIT NOR ACCEPT BARTER.
~ ALL ISSUES EXPRESSED IN TERMS OF FREQUENCY EQUIVALENTS ~
