Release form for frequency treatment

[Richard Di Nucci]

Release Form for Rife Frequency Treatment – Revision 3

( note: recent additions/changes are shown in red)

I, _________________________ fully acknowledge the implications of the following six (6) paragraphs listed below; further, I fully understand, acknowledge, and accept the potential consequences either expressed or implied by these statements below.

1. I have received a “Rife" device, Model # ___________________ (hereinafter referred to as “device”) on temporary loan, for a maximum period of two weeks, from ________________________ on the date shown below. Further, while in my possession, I am responsible for the safe-keeping of this device.

2. I have been trained in the specific procedures that are to be used in connection with the safe operation of this device, and I have been trained in specific safety precautions that are to be followed, before, during and after the use of this device.

3. While in my possession, this device is to be used on an experimental basis by me only, and for the expressed purpose of treating my own ailment(s), which I characterize as follows: ________________________________, __________________________, and _________________________________. (To All: Does this second portion of Paragraph # 3 sound OK to leave in, or should we delete any reference in this Release Form to "treatment of ailments"?)

4. Use of this device is for experimental purposes only.

5. Though the maximum duration in my possession is specified in Paragraph # 1 as two (2) weeks, the device owner may request the return of this device after three (3) days, if necessary.

6. The device owner is receiving no compensation of any kind for allowing me to borrow this device.

Signed below by the Owner and the Temporary User of this Device:


_______________________________________
Temporary User of Device Date

_______________________________________
Owner of This Device Date


Question to Forum Members: Does anyone have additional suggestions/ changes? Or is there another “template” other than this draft above that will suffice?
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