BioAcoustic Biology Research Studio
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   ~~~~~~~   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
Name ________________________________________________________________ Birth Date_______________________________  

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.
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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.

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                         Signature                                                                                                             Date

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                        Printed Name   
SUBMIT
                      ~~~~~~~   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.


~ ALL ISSUES EXPRESSED IN TERMS OF FREQUENCY EQUIVALENTS ~

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