Release Form Page

NOTE: I DO NOT GIVE OUT YOUR PERSONAL INFORMATION TO ANYONE. I DO NOT use your information for anything other than to keep it as proof that you acknowledge that you read and understand the information below, and to contact you about the session you’re receiving. My preferred contact method is email. If you don’t answer your email within 2 days I will call you instead.

IMPORTANT NOTE: In order for Carmen to serve all her clients and Customers, she has implemented a no-reschedule and no-refund policy.

(You will receive the Distance Energy Healing/ Advanced Quantum Biofeedback Session that you paid for at the scheduled appointment time after you set up your appointment with Carmen.)

Thank you for your cooperation!

RELEASE/CONSENT FORM

1. I, L. Carmen Croitoru, am not a medical physician or surgeon nor do I practice in that model, therefore I do not prescribe legend drugs or make recommendations about them, but will make referrals when requested or when I feel there is a need for that model.

2. You, the client, are NOT to discontinue any medical treatment or medication without supervision and consultation from your treating physician.

3. You, the client, are accepting services under good faith and free will, and following the dictates of your own conscience, which allows you to select what you understand is most beneficial to your health, and are accepting these services without guarantees.

4. You, the client, understand that the SCIO biofeedback procedures utilized include stress reduction protocols, relaxation techniques, and pain management. The lawfully registered SCIO biofeedback device is intended for the purposes of relaxation, reducing stress, and muscle re-education and is legal to be used for those purposes. I, L. Carmen Croitoru, warrant that all biofeedback equipment to be used during any biofeedback sessions with clients will be lawfully registered with the appropriate governmental agencies as required by law.

5. This work is both alternative to and at the same time complementary to the biomedical model of Western medicine licensed by the state. The holistic/wholistic approach involves the assumption that when one thing changes you change as a whole person.

6. There are no licensing bodies or requirements in this state for the Energy Healing, Reconnective Healing®, Soul Body Fusion®, Touch for Health®, Brain Gym®, ‘The Magic Box’, and Biofeedback models of health enhancement and therefore this service is not licensed by the State.

7. Energy Healing, Reconnective Healing®, Soul Body Fusion®, Touch for Health®, Brain Gym®, ‘The Magic Box’, and Biofeedback are models of natural enhancement that have as their basis energy. Energy Healing, Reconnective Healing®, Soul Body Fusion®, Touch for Health®, Brain Gym®, ‘The Magic Box’, and Biofeedback are about bringing people back to a natural state of balance, wholeness, and vitality. This system is available to all people and professions, is not dangerous to use, and does not require a license by the state. However, healthcare providers licensed to diagnose, treat, cure or prevent any disease or disorder may use biofeedback devices for any purpose permitted by their license.

8. I, L. Carmen Croitoru, am a Certified Biofeedback Specialist (CBS), Reconnective Healing® Foundational Practitioner, Reconnection-Certified Practitioner, a Brain Gym® Consultant, have my Touch for Health® Proficiency, and am a Soul Body Fusion®, ‘The Magic Box’ and Biofeedback® Practitioner. I successfully completed the Certified Biofeedback Specialist program, as well as both the Reconnective Healing® Foundational Practitioner Program and the Reconnection-Certified Practitioner Program. I have also successfully completed the programs to become a Brain Gym® Consultant and Touch for Health® Proficient. Again, I am not a medical physician or surgeon nor do I practice in that model.

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NOTE: I DO NOT GIVE OUT YOUR PERSONAL INFORMATION TO ANYONE. I DO NOT use your information for anything other than to keep it as proof that you acknowledge that you read and understand the above information, and to contact you about the session you’re receiving. My preferred contact method is email. If you don’t answer your email within 2 days I will call you instead.

**Your signature below indicates that you have read and understood the information in this document and that you consent to training under the provisions stated. If you do not understand or consent to anything stated in this document, it is your responsibility to request and receive clarification before signing.

By entering your name below, you agree to the conditions listed above.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone Number

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Is the above phone number a Cell/Mobile phone number?

In case you don't reply to the email I will send, and you don't answer the phone, I'll text if this is a Cell/Mobile phone number.

YES, it is a Cell/Mobile phone number.

NO, this is a Landline phone number.

As an energy intuitive/sensitive/psychic/healer, Carmen can make the same guarantees that your doctor can make – that there are No Guarantees.

**CARMEN IS NOT A MEDICAL DOCTOR. THESE PRODUCTS SHOULD NOT BE USED AS A SUBSTITUTE FOR SOUND PROFESSIONAL ADVICE.

*THESE STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. THESE PRODUCTS ARE NOT INTENDED TO DIAGNOSE, TREAT, CURE, OR PREVENT ANY DISEASE or health condition. Zappers of any kind are NOT APPROVED for use by any US Federal authority. Their use is to be considered experimental, and you are a de facto researcher.

*** by purchasing anything from carmen, you agree to do your own research before using anything and hold carmen harmless against anything bad that might happen to anyone, anywhere, ever.