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

Allergies?(Required)

Do You Use an EpiPen?(Required)

Yes

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..

How did you hear about us?(Required)

Sound Health Options website

Search engine

Radio show

Friend or relative

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 FREE initial consultation.

Yes

Tone Box Equipment(Required)

I understand that 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 must be returned to BioAcoustic Health upon completion of those services at my expense.

Yes

Next Steps

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

1.  Please contact us after you have filled out this form so we can schedule a time to record a voice print. Most likely we will do this together via Zoom. We will also do all initial customer set up, which will take about an hour. Please be at your computer (if applicable).

2.  Once your voice is recorded, it may take 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.

3. We will send you an invoice when your report has been started. Shipping costs will be extra, depending on client's location. Once payment is processed, we will ship your tone box and send a tracking number. We will also send your assessment and any supporting documents and/or information.

4. Once you receive your report and/or tone box, please contact us to schedule a time to go over your assessment, including tone box instructions.

- Disclaimer -

Signature(Required)

Please use full name in your signature.

Date(Required)

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