Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Are you currently pregnant? *

Yes

No

Would you like an mp3 recording of your personalized sound bath? *

(an additional $15 fee)

Yes

No

I'm not sure

Please check each box below to acknowledge that you have read and understand each statement. *

I understand that sound healing sessions are not psychotherapy appointments, and that Dr. Scott performing sound healing for me does not make her my psychotherapist, or make me a psychotherapy patient.

If I experience pain or discomfort during the session, I will immediately inform my sound therapist. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. I understand that I may experience physical sensations as a result of this sound healing session.

I understand that a sound healing session is not a substitute for medical care. I also affirm that I have notified my sound therapist of all known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I fail to notify of any conditions.

Sound Healing is contraindicated for certain medical conditions (listed above). I affirm that I have discussed all my known medical conditions with the sound therapist, and completed the information on this consent honestly. I understand that I should see a physician or qualified medical specialist for any mental or physical ailment of which I am aware. I agree to keep the therapist updated as to any changes in my medical/physical conditions that might affect my ability to safely receive sound healing.

I understand that if I do not pay for my session at least 24 hours prior to my scheduled appointment, my appointment is NOT confirmed, I am not guaranteed my initially scheduled appointment time, and I may have to reschedule the appointment.

I understand that I may ask for a copy of this waiver form by emailing dralyciascott@dralyciascott.com.

By digitally signing this release, I consent to receiving sound healing from Dr. Alycia Scott, and hereby waive and release Dr. Alycia Scott of Open Lotus Sound from any and all liability, past, present and future relating to receiving sound healing from Dr. Scott.