Health Questionnaire

Please fill out the following form
in order to participate to thesound bath..

First Name

Last Name

Email

Do you have a hearing aid?

No

Yes

Do you have an implant of any kind in your body?

No

Yes

If you answered yes, please confirm what implant it is and the daeif its isertion.

Are you pregnant?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

Anything you feel we need to know prior to your experience?

No

Yes

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Cristina Patel

Advanced Theta Healing® Practitioner & Instructor| Certified Access Bars® Practitioner | Qualified Sound Therapist

bottom of page