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READ Consent type "agree" in both windows

if you agree

if you "agree" to terms of service type agree in all windows*

CONSENT FOR REMOTE DISTANT TREATMENT /SERVICES This is a disclosure & consent for treatment via electronic means and is a viable lawful act for the use of agreement, if you do not agree, do not type the word "agree" in any blank window / both windows as instructed to do for the consent.

check all that apply to you*


PHONE CALL 307-670-9014

IN PERSON @ 439 Prairie View Drive suite A

Gillette WY

or, IN WRITING email -

Email Address*



Consent Message & Personal History*

I, hereby authorize consent to my participation in the use of SP2 Frequency Remote Device, through software to my DNA for remote sessions; including Detoxing, FSM, Rife programs selected according to my personal consultation with practitioner either by in-person, over phone, or written testimony of my health conditions, that I choose together or allow to be chosen for me to treat to my body/system through my DNA supplied for this process and understand that this is the processes of QE; quantum entanglement, allowing, by and through my trust & faith in the process having & receiving the remote treatments. I have read the attached information pertaining to the process and I completely agree, fully without duress, thus, allowing the Practitioner of Harvest Health – Rhonda Kay Curry, Certified Practitioner in Auriculotherapy & Frequency application with Biofield Energy Balancing, to perform any selected programs that I agree to have run on my DNA for the support to my health & healing processes. **AS A FEMALE; I AM NOT PREGNANT X___TYPE THIS IN MESSAGE__ Initial ** I have surgical implants __LIST THESE IN MESSAGE W/PROCEDURE____ and or have a defibrillator ___ and or a pacemaker___ (LIST THIS IN MESSAGE if applies) I understand that I should call HHB office 307-670-9014 and leave a detailed message if no answer / or TEXT the After hours # or, will feel free to walk-in to Harvest Health if any issues, questions or concerns arise relating to any services obtained. You also agree to keep a log of any results and to share those results as part of the plan having these Remote treatments. This consent protects both you & the owner of Harvest Health from harm or arbitration in what-so-ever as associated in possible dissatisfaction of results keeping in mind that you trust the process, keep a positive mindset, drink plenty of purified water and work alongside the practitioner performing all suggested protocols to obtain positive outcomes, you agree to not slander the process, as some have been known to do for centuries. Furthermore, you understand Naturopathy practices are solely of a natural process, the Practitioner is not claiming to heal or diagnose, and the treatments are not fda approved, even so, are considered completely safe. You agree this approach to healthcare is meant to support the body’s natural healing process through time management, communication & teamwork. By typing "AGREE" in BOTH sections, this indicates and performs as an electronic signature is as your signature indicates that you do fully agree to this in its entirety for the REMOTE sessions / services which can include any or all suggested services, advice or other as assisted protocols. X____TYPE "AGREE" only if you agree TYPE IT BELOW AND ABOVE__ w/DATE ______ AND in this Message Field type any valuable information about your Health History that you can share that will further help & assist in the process towards your goal.

I agree to the terms & CONSENT to Remote *

Download this Form to complete & bring with you to the Appointment

print out scan and return via email

or usps mail

or send now & read form below -

use space to type "agree" only if you agree

- agree again  if you fully agree to the consent

of the terms of remote services




 > information of the Rifing process < please read

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