Application

In connection with my application for advice based on Maharishi Vedic Vibration Technology, I the undersigned:

(your name, address, phone number etcet.)

have understood that Maharishi Vedic University and its collaborating organizations do not make any warranties or representations concerning any specific results or effects with respect to Maharishi Vedic Vibration Technology. I hereby confirm that I fully understand that this programme is not intended as a replacement of any medical care that I am now receiving or that I may require in the future. I acknowledge that I have been advised to continue to take advice from my family doctor and any specialists with whom I have consulted. Should I feel better, I will take my doctor's advice before reducing or discontinuing any treatment that I am or may be receiving.

I have provided information about my physiological condition in order to enable experts in Maharishi Vedic Vibration Technology to determine the Instant Relief programme that is most suitable for me. I understand that the questionnaire provided to me is for this purpose, and that it is very important to provide information that is as accurate and complete as possible. I promise to report the results of this programme, and I agree that my reports or parts of them are publicized (without mentioning my name).

I understand that my health insurance company may not cover the costs of this programme. Out of my own free will I have decided to apply for participation in Maharishi Vedic Vibration Technology.

I understand that all the information that I provide will be kept confidential.

(your signature)