Admin Page Registration and Release Template

PLEASE ENTER YOUR FULL LEGAL NAME
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Address
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- Street Address
- Address Line 2
- City
- State / Province / Region
- Postal / Zip Code
- Country
Email Address
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Phone Number
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1. INFORMED CONSENT FOR RECEIPT OF ENERGY WORK: (click each box)
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I understand that Marconics is a holistic and integrative energy based therapy that is accomplished through the use of both physical and non-physical contact.
Marconics Energy Healing Protocols are intended to help me balance and release energy blocks in my human energy field to promote my ability to support the healing of my physical, emotional, mental, and spiritual disorders and diseases.
Marconics Energy Healing Protocols are NOT a substitute for medical or psychiatric treatment or medications. It is recommended that I consult with my primary physician or psychologist/counselor for any condition I may have.
2. MARCONICS MEDICAL DISCLOSURE FORM. Marconics is a therapeutic energy modality designed specifically to upgrade the subtle bodies for Spiritual Ascension. These powerful protocols can result in immediate and rapid clearings of the emotional, physical and mental bodies - requiring a balanced and robust constitution. If the body’s natural homeostasis is already impacted by certain medications, or by electrical implants - such as valves or pacemakers – one, or multiple sessions may result in a healing crisis. Although it is physically safe, the harm may arise through the associations which are then drawn by you, and/or your physician between the symptoms of energetic clearing - which can mimic anxiety - and a pre-existing condition. To avoid conflict in this area we request transparency as to any debilitating physical, emotional or psychiatric conditions you may have, or have been treated for in the past, that could be impacted this way. We also request that you reveal the presence of any medications in your system, either through your treating physician, or through self-medication, inclusive of plant medicines such as psilocybin mushrooms, ayahuasca, and marijuana. Treatments for depression or anxiety particularly, from our experience, may carry contraindications leading to a temporary worsening of the symptoms. In light of the information you may share with your practitioner/teacher, we may consider it necessary for you to request a letter from your physician saying you are fit to receive energy work. Or, require that on being informed of the risk, you agree to sign a waiver accepting responsibility for the outcome of the session. Any personal medical information you choose to share with your practitioner will be treated as privileged and confidential. It is your right to refuse and protect your medical data. [Check the box below to acknowledge this disclosure. Then check box 2.1. to consent to share, OR check box 2.2 to decline to share]
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I have read (or have been read) the requests on this disclosure form.
2. 1. I hereby agree to share some or part of my medical history that may be relevant to me energy session. (Please check the box and complete the Health History and Prescription List Below - Section 2.3.)
2. 2. I hereby refuse to share any part of my medical history and have agreed to sign the aforementioned waiver. (Please check the box below)
I have been advised that any pre-existing medical or psychiatric conditions or concerns that I may have with regard to my ability to participate in the Program or receive energy through Program or Service should be discussed and cleared by my primary care physician prior to my attendance. I take full responsibility for my choice to consult my physician (or not) and agree to indemnify and hold harmless Marconics International LLC, its owners, the Teacher(s), Practitioner(s), Employee(s) and Intern(s) representing from and against all claims, damages, liabilities, losses and expenses of any kind arising out of my participation in any Marconics Programs or Services.
Type your name below to electronically sign the medical history waiver:
2. 3. HEALTH HISTORY Please indicate if you have a history with any of the following: Check All That Apply
Alcohol Abuse
Anxiety Disorder
Cancer
Depression
Diabetes
Electrical Implants
Hearing Impairment
Mental Illness
Migraines
Pregnant (currently pregnant or nursing)
Seizures/Epilespy
Suicide Attempt
OTHER
NONE
If you checked any boxes above, please provide a brief description below
USE OF PRESCRIPTIONS OR OTHER DRUGS Check All That Apply
Anti-anxiety
Anti-depressants
Anti-psychotics
Anti-seizure
Insulin or Other Diabetes
Plant Medicine: Ayahuasca
Plant Medicine: THC or CBD
Pyschedelics: Mushrooms, LSD, DMT
Radiation or Chemotherapy
OTHER
NONE
If you checked any boxes above, please provide a brief description below
3. During Marconic Energy Healing Sessions:
I may experience tingling, hot or cold sensations, lightheadedness, or emotional release during a session. I will inform my practitioner of any uncomfortable sensations or physical/emotional distress during or after treatment.
I understand that the session may involve the use of touch on my fully clothed person in a professional manner that is consistent with Energy Therapy Techniques. I will inform my practitioner if there is any area on my person that I do NOT wish to be touched.
I understand that Marconic ‘No-Touch’ Sessions, Integrated Chakra Unifications, and Quantum Recalibrations are performed in the energy field around my body and touch is not a part of the session, but I may be touched on my shoulders, knees and feet to help me settle and ground energy.
4. INDEMNIFICATION: I agree to this indemnification clause and hold harmless Marconics International LLC, its owners, the Teacher(s), Practitioner(s), Employee(s) and Intern(s) representing Marconics from and against all claims, damages, liabilities, losses and expenses of any kind arising out of my participation in any Marconics Programs or Services.
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I agree
5. SESSION FEES & CANCELLATION POLICY: All Deposits and Final Payments for Appointments are non-refundable. Should you miss your appointment, no refunds are granted.
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I have been made aware of the cancellation policy
I have been informed of the fee for my Marconic Energy Healing Session and understand that while I may stop my session at any time, fees are non-refundable as my appointment time has been set aside for me. a
6. ELECTRONIC CONSENT: I consent to using an electronic signature by typing my name below: Type your full legal name
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Date
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Thank you for booking a Marconics Session

Please complete this form in advance of our session

If you are unable to complete this form electronically,

please contact:

Melinda Asztalos, 905-635-5030, melinda5475@gmail.com

Thank you for booking a Marconics Session

Marconic Energy Healing Session:

Client Informed Consent