New Client Forms
We’re delighted for you to experience Oklahoma’s first Theta Chamber. Please complete the New Client Intake Form and the Consent Agreement and Liability Waiver prior to your first visit.
New Client Form
Consent Agreement and Liability Waiver
2. I fully understand that the technician who is assisting me is prohibited from diagnosing or treating any disease, condition, or illness by prescribing medication, offering medical advice, or providing any other medical services.
3. I fully understand that any analysis conducted is strictly educational in nature and does not diagnose, treat, cure, or prevent any disease.
4. I fully understand and acknowledge that OK Theta & Wellness uses subtle energy, frequencies, vibration, and resonance to interact with the body’s energy field and measure my body’s response. When it encounters imbalance, it reports those imbalances to me and helps optimize my wellbeing by identifying frequencies that may restore balance.
5. I fully understand that any analysis provided by OK Theta & Wellness uses leading-edge technology that is not yet generally accepted by conventional health care professionals. Services provided by OK Theta & Wellness are not covered by medical insurance.
6. I fully understand that any payment for any therapy is expected at time of booking, unless otherwise arranged prior to my session.
7. I acknowledge that the US Food and Drug Administration has not evaluated any statements made regarding OK Theta & Wellness in general, or regarding any of the specific therapies offered. Again, our services are not intended to diagnose, treat, cure, or prevent any disease.
8. I affirm that I am acting of my own free will and according to the dictates of my own conscience to experience services and therapies offered by OK Theta & Wellness.
9. I affirm that I do not represent, nor am I an agent for, the American Medical Association or any state or federal regulatory agency.
10. I affirm that I am requesting these services and therapies for myself and not for legal recourse.
11. I affirm that I have consulted with my physician prior to using the Theta Chamber about any of the following conditions: Pacemakers, Internal Defibrillator, Internal Insulin Pump, Prone to Seizures, or Light Sensitivity.
12. I affirm that I will not enter the Theta Chamber under the influence of drugs or alcohol.
13. I fully understand I should lay still and not try to sit up during a treatment in the Theta Chamber.
14. I give the technicians at OK Theta & Wellness permission to assist me with putting on headphones, CES ear clips, and light goggles.
15. I fully understand that during my treatment I will be given a remote with a stop button. I may press the button at any time during my treatment. If I choose to stop a treatment early, my treatment session will end for the day, and no money will be refunded.
16. I fully understand that during my treatment, I will have the option of turning on the pulsed electromagnetic field (PEMF) mat. I fully understand that absolute contraindications include implanted devices (pacemaker, defibrillator, insulin pump, cochlear implant, pain pump, etc.) and that PEMF has not been proven safe for pregnant women.
17. I fully understand that PEMF therapy is contraindicated for children who have not yet completed their growth phase.
18. I affirm that I have consulted with my physician prior to using the PEMF mat about the following conditions: severe arrhythmias, atherosclerosis, myasthenia gravis, active bleeding, hypothalamic dysfunction, hypophyseal dysfunction, hyperthyroidism, adrenal gland dysfunction, acute viral diseases, active tuberculosis, mycosis, malignancies, psychoses, epilepsy or seizures, magnetisable prostheses, and organ transplants.
19. I fully understand I must remove all metal jewelry, cell phones, electronics, key fobs, credit cards, and anything with a magnetic strip if using the PEMF mat.
20. With the acceptance of this consent agreement and liability waiver, I hereby waive and release myself and my heirs, executors, and administrators, from any and all claims of any nature whatsoever and do hereby acknowledge that I will use the services provided at my own risk. I confirm that I have given accurate legal direction and that I am of legal age in this jurisdiction.
Please sign below, indicating that you have read, understand, and agree with the statements above. The following is to be completed by the patient or by the patient’s representative, if necessary, e.g.; if the patient is a minor or physically or legally incapacitated.