Client Health Questionnaire & Waiver

Please take a moment to carefully complete the following information and sign where indicated. A red * indicates a required field.


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    Please rate your average stress levels on a scale of 1 to 10 during the average week (1 = no stress) *

    Please rate your average energy level on a scale of 1 to 10 (1 = no energy) *



    Please Elaborate

    I acknowledge and accept the risks inherent in the use of the BioCharger. I voluntarily assume the risk of injury, accident, or death, which may arise from the use of the BioCharger. I and any of my heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal injury or property damages of any kind sustained while on the premises, during the use of the BioCharger and from any advice provided by an employee, independent contractor, or any representative of Revive Health, LLC. I agree that this Application and Waiver is in effect for all BioCharger sessions and will not expire unless requested by either party.

    Revive Health, LLC and its representatives, including but not limited to BioCharger, does not provide medical advice, diagnoses, or treatment. BioCharger may or may not be appropriate for you. The BioCharger is only used as an adjunctive therapy and is not intended to replace any medical treatment from my doctor. Do not attempt to self-treat any disease with the BioCharger. Please consult your health care provider for medical advice. I further acknowledge that Jill Durand from Revive Health, LLC is not a doctor and any advice on dietary changes or restrictions, including taking supplements, is to be done at my own risk.

    Individuals who do not cancel their appointment within 24 hours will be charged a $20 cancellation fee.

    This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.