(if retired, please state what you are retired from)
(how did you hear about my services?)
Please rate each symptom on a scale of 1-10, with 10 being the worst.
I, THE UNDERSIGNED FOR MYSELF OR ON BEHALF OF ANY MINOR INDICATED BY ME BELOW, AGREE TO THE FOLLOWING:
I understand that Energy Healing / Pranic Healing® practitioners are not licensed physicians or surgeons, and Pranic Healing® treatments are not licensed by the state but are complementary to healing arts services licensed by the state.
That Energy Healing / Pranic Healing® practitioners do not physically touch the recipient’s body, diagnose diseases, prescribe any drugs/substances or make any health claims or guarantee any outcomes. That although this is a healing modality, and the goal is to improve my health, I understand that unexpected or unanticipated results may occur.
That Energy Healing / Pranic Healing® is not meant to replace conventional medicine but rather to complement and enhance it. If symptoms persist, I agree to consult a medical professional. I agree to provide updated and current information in the event any the status of any of the conditions (listed above) changes. I understand that I am responsible for my own safety.
I expressly accept all risks associated with this activity and voluntarily assume full responsibility for all the consequences of my choosing to engage in Energy Healing / Pranic Healing®. I hold Heart to Heart Healing, LLC and Liza Burney harmless for any death, injury, damage, or loss which I (or any minor on whose behalf I sign this contract) might suffer as a result of participation in this process, including any injuries or damages which result from another's negligence or fault.
I have read and accept the terms of this liability disclaimer agreement.
As a parent or legal guardian of a minor under 18 years of age who will participate in and receive Energy Healing / Pranic Healing® treatments; I have read this contract and document and sign this release on his or her behalf. I understand and agree that every provision in this contract applies to the minor on whose behalf I sign this contract, just as it would apply to me if I were signing it for myself.