Client Intake Form | Enlightened Sound

Enlightened Sound Intake / Waiver Form

To ensure your sound bath experience is as safe, supportive and relaxing as possible, I ask all attendees to complete this short intake / waiver form before their first session. If there are any changes to the information you supply to me below, please ensure that you fill in a new form. Many thanks.

First name

Last name

Phone

How did you hear about Enlightened Sound?

Please tick this box if you would like to receive information on future Enlightened Sound events and treatments

I am 18 years of age or over.

If you are a parent/guardian and you are attending a sound bath with your child, please specify your relationship to the child, their age and any other relevant information in the box below.

Have you experienced a sound bath before?

Yes

Please select the date of the sound bath you intend on attending.

If someone else / organisation purchased your ticket on your behalf, please fill their name in the box below.

Do you have any medical or mobility issues that Emma needs to be aware of?

Yes

If you answered yes the question above, please supply additional information

Do you have any allergies that Emma needs to be aware of?

Yes

If you answered yes the question above, please supply additional information

The sound baths Emma Wells IBHM hosts are not suitable for some medical conditions and you are not permitted to attend under the influence of alcohol or illegal drugs.

Sound healing should not replace conventional medicine. Instead, it should be considered as a complementary therapy to use as part of your own self care practices.

To get the most from your sound bath a 'Self-Care After Your Sound Bath' information can be found on the Enlightened Sound Website and is recommended to read before attending.

Medical Exclusions List

1st Trimester of Pregnancy
Sound induced Epilepsy
Pacemakers

If you are subject to any of the listed medical exclusions you should not attend a sound bath with Emma.

Medical Contra-Indications

Pregnancy outside 1st Trimester
Seizures
Severe sleep apnoea
Medical electrical devices
Implanted Stents or mechanical shunts
Recent & active blood clots
Brain Surgery
An acute mental health condition
Severe sound sensitivities
Heart Conditions

If you are subject to any of the listed medical contra-indications, you should consult with your doctor before attending a sound bath. Only your doctor knows your full medical history and is legally qualified to give an accurate diagnosis of your suitability to take part in a sound bath.

Proceed with Caution Recommendations

Metal Implants.
Recent surgical scars or serious injuries.
Muscular Soreness
Mobility Issues

If you are subject to any of the proceed with caution recommendations or have any other concerns, please make Emma aware before the sound bath.

*By signing your name in the I confirm box below, you have confirmed that you have read and checked the Medical Exclusions List, the Medical Contra-indications and the Proceed with Caution Recommendations information, and that you accept full responsibility for attending a sound bath with Emma Wells and that of any future sound baths with Emma Wells IBHM of Enlightened Sound Norfolk.

I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage or loss that may result from my participation. I hereby waive and release Enlightened Sound, Emma Wells IBHM, the business, its owners, and its staff from any liability, past, present and future, relating to the services provided.

I confirm Signature

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Date of confirmed signature

Day

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