Client Application Form

Become Our Client

Name of Client(Required)

First Last

Email(Required)

Email Confirmation(Required)

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Address(Required)

Is this the same as your Home Address?

Yes

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone (if available)

Leave a Message on Home Phone?

Yes

Cell Phone

Leave a Message on Cell Phone?

Yes

Best Time to Call (Include Time Zone)(Required)

Date of Birth(Required)

Favorite Color(Required)

Are you Currently Experiencing Pain?(Required)

Yes

If so, what is your pain level (1 being the least and 5 being the most):

Pregnancy - Currently or Plan to Be Soon

Yes

Do You Smoke (nicotine or marijuana)?(Required)

Yes

Have You Smoked in the Past (nicotine or marijuana)?(Required)

Yes

Do You Drink Alcohol?(Required)

Yes

How Often do you Drink Alcohol?(Required)

Occassionally

Once a week

Twice a week

Three times or more a week

Do You Take Recreational Drugs?(Required)

Yes

Are you a vegetarian?(Required)

Yes

Under the Care of (Physician's Name):

Current Issues(Required)

Select the issues that you are CURRENTLY experiencing. Please choose all that apply.

Diagnoses

Have you been diagnosed with any of the following? Check all that apply.

Do You Have Allegies?(Required)

Yes

Do You Use an EpiPen?(Required)

Yes

Allergies?(Required)

Do You Have a History of Seizures?(Required)

Yes

What ailments are you hoping to address?

Medications and Supplements:

Please include all Vitamins, Minerals, Herbs, etc..

I would like to participate in a collaborative study using The Shift Device.

We are currently starting a study in collaboration with Dr. Kate Keville and The Shift Device. If you have purchased the handheld device that helps raise your electromagnetic field that potentially increases your ability to heal, please let us know. You can follow this link for more information on The Shift: https://65a912-42.myshopify.com/robertacuffin_bah

Yes

How did you hear about us?(Required)

Search engine

Radio show

Friend or relative

Previous student

Other

Computer Specifications(Required)

For remote clients, having access to a computer is required. Some free open source applications are required and will be discussed during initial consultation and client onboarding session. Please mark all that apply.

I use a Windows-based Computer

I use a MAC

I have access to a Windows-based computer

I DO NOT have access to a Windows-based computer

Additional Equipment(Required)

I understand that some of our services may require additional equipment. These may include proper microphone and headphones. These details will be discussed in your initial consultation, or you can find that information under the FAQ section.

Yes

Tone Box Equipment - Not Required(Required)

I understand that if desired, I will have use of a Tone Box generator for the duration of BioAcoustic services that include frequencies. I also understand that the Tone Box requires an additional fee and must be returned to BioAcoustic Health upon completion of those services at my (the client's) expense.

Yes

Other equipment: Microphone

In order to get the best vocal recording, an external microphone is suggested. If using an external microphone, you must use one with a cardioid setting, which means that only sounds in front of the microphone are recorded. (Sound checks are still advised.) The FIFINE USB Microphone is one affordable option. You can purchase from Amazon for ~USD$30, but you can find other options, as well.

I will use an external microphone

I am NOT able to use an external microphone

Other equipment: Headphones

We personally check all suggested equipment for effectiveness; therefore, you must use one of the headphones we suggest, which are either the Koss KTX Pro1 (on ear) or the Panasonic RP-HT161K (covers ear). Please be advised that these might have other model numbers if ordering in other countries. If you would like us to look at the specifications of ones you already own, please give us the brand name and model number below. If using others with similar specifications, we cannot guarantee sound quality.

Other equipment: Headphoness

I understand I must use the required headphones to receive the full benefits of sound therapy from BioAcoustic Health protocols.

Yes

Next Steps

Your business is important to us. Please follow the steps below for a smooth process.

1.  Please make sure you have the required equipment.

2.  Please contact us after you have filled out this form so we can assist you in recording your voice. We can either give you the password for our Recording Page or schedule a time to record a voice print together.

Most will use this with their computer to record, but if you prefer to use a cell phone, we will advise on how to get the best recording.

3.  Once your voice is recorded, it will take an average of 2 weeks to finish your assessment, depending on the number of clients we have at that time. Please be patient. There is a lot of information for us to go through to create your assessment.

4. We will send you an invoice when your report has been started. If choosing a tone box, shipping costs will be extra, depending on client's location. Once payment is processed, and if so desired, we will ship your tone box and send a tracking number. We will also send your assessment, playlists, listening calendar and additional information.

5. Once you receive your report and/or tone box, you can schedule a time to go over your assessment, including tone box and/or listening instructions, if desired.

- Disclaimer -

Signature(Required)

Please use full name in your signature.

Date(Required)