Forms | Fundamentally Harmonic

Fundamentally Harmonic Covid - 19 Waiver

*To be filled out THE DAY of your scheduled appointment.*

First Name

Last Name

I have not experienced any COVID-19 symptoms or a fever of 100.4 or higher in the last 14 days.

I have not been in contact with anyone who is suspected or confirmed to have COVID-19 in the past 14 days.

I have not travelled in the past 14 days either: internationally, by cruise ship or domestically outside of NH, VT or ME on public transportation (bus, train, plane, etc.)

I have not been in a group setting, hospital, or extended care facility in the past 14 days where social distancing was not possible.

If working in an environment where social distancing is not possible, all PPE was worn and all CDC recommendations were followed.

I will wear a mask at all times while I am in the building, office, and during our Sound Healing Session.

I understand the precautions that Marybeth Hallinan is taking to assure my health and safety.* I do not hold Marybeth Hallinan, of Fundamentally Harmonic, liable in the case of my contracting COVID-19. I assume all risks and understand that it is my choice to receive treatment. If at any time I am uncomfortable, it is my responsibility to convey my concerns.

Your Signature

Date

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

Thanks for submitting!

Waiver and Intake Forms

Please complete these two forms prior to your scheduled appointment.

Fundamentally Harmonic Covid - 19 Waiver

New Client Intake Form

Waiver and Intake Forms

Please complete these two forms prior to your scheduled appointment. ​​​

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Fundamentally Harmonic Covid - 19 Waiver

New Client Intake Form

Please complete these two forms prior to your scheduled appointment.