Update Payment Information Form Please enable JavaScript in your browser to complete this form.Client InformationName *FirstLastPhone *Email *Names of All Clients / Family Members (Including Yourself) To Be Treated On This Card *Payment InformationName on Card *Cardholders Email Address *Card Type *Card TypeVisaMasterCardAmerican ExpressDiscoverCredit Card Number (No Spaces or Dashes) *Expiration Date (MM/YY) *CVV (Security Code) *Billing Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDisclaimer Overview Quantum Techniques (QT). are not intended to diagnose, prescribe, treat, or cure any disease, physical or mental. The use of Quantum Techniques (QT) by a QT practitioner should not be construed as a prescription, a promise of benefits, claims of cures, or a guarantee of results to be achieved. The information, instruction or advice given by a Quantum Techniques practitioner is not intended to be a substitute for competent professional medical or psychological diagnosis and care. You should not discontinue or modify any medication presently being taken pursuant to medical advice without obtaining approval from your healthcare professional. As a Quantum Techniques client, you must take complete responsibility for your own physical health and emotional wellbeing. Quantum Techniques consists of self-help coaching techniques and tools, within the category of “energy therapy.” A client learns and uses Quantum Techniques to balance their own body’s energy system with the intention of reducing stress, enhancing overall health, and removing dysfunctions in the body's bioenergetic system. Quantum Techniques and its practitioners believe that it is the client who heals himself/herself, and that the Quantum Techniques techniques and tools simply assist the client in this process. Every Quantum Techniques client is unique, and therefore, each client’s experience with Quantum Techniques may be unique. Quantum Techniques is not a substitute for regular medical or psychological care. Quantum Techniques is not about disease or illness—rather, its focus is on healing and wellness. Medical authorities do not recognize this work as “medicine”. We agree. There are researchers in this area who believe there is a correlation between the detection of certain energetic frequencies and the presence of disease states or organisms in the body. Energy therapies, like Quantum Techniques, may be able to identify the unhealthy frequencies years before a physical disease manifests in the body. As a person heals those frequencies, health is enhanced. Our work, which includes evaluations and scans of the subtle-energy field, is strictly limited to address the imbalances in the subtle-energy field. For example, in our scans we may talk about the frequencies of virus, bacteria, fungus and parasite issues. We are only saying that we have often found those frequencies when our clients are in a non healing state. Commonly, people who manifest those frequencies over time experience patterns of deterioration in the way they feel. As those frequencies are cleared and the energy field is balanced, they typically experience a return to feelings of wellness. We cannot determine if the client actually had a virus, bacteria, fungal infection or parasite. We cannot determine if a client actually has Multiple Sclerosis, Parkinson’s disease, Manic Depression or HIV, for example. Testing for that is beyond our expertise. For those determinations, we refer clients to their M.D. or licensed health care professional for appropriate tests. No one is advised to discontinue or to avoid medical or psychological consultations. There are cases where medical or psychotherapeutic consultations are advised. Don’t use these techniques to try to solve a problem where your common sense would tell you it is inappropriate. Since these are self-treatment techniques, we cannot and will not take responsibility for what you do with them. You are required to take complete responsibility for your own well-being both during and after the use of our materials and/or coaching sessions. Some statements on web site, https://www.quantumtechniques.com, manuals and products represent working theory rather than accepted science. Quantum Techniques practitioners practice as bioenergetic consultants, not as licensed medical doctors, psychologists, psychotherapists, chiropractors, lawyers, nutritionists, or naturopaths. Although these techniques are being used by therapists, health professionals and lay people worldwide, the practice of Quantum Techniques and bioenergetic consulting is not currently regulated by any licensing board in the United States. Any spiritual counseling provided by Quantum Techniques practitioners is not part of any recognized religion. We have not personally experienced any adverse side effects when applying the gentle techniques of Quantum Techniques when the treatment protocols and suggestions were followed. This does not mean, however, that you will not experience or perceive negative side effects. If you use these techniques on yourself or others, you must agree to take full responsibility for your own well-being and you are required to advise others to do the same. You must understand that while an energy healing approach is a safe self-treatment method, with a substantial body of clinical experience showing no serious side-effects when properly administered, it is possible, with any form of healing, that unresolved memories and related emotions and sensations may be brought into your awareness. It is possible that this emotional material may continue to surface after the coaching session and require further self-treatments or coaching sessions. It is also possible that previously traumatic memories may lose their emotional charge, and this could adversely affect your ability to provide legal testimony that carries the same impact as it might have prior to treatment. In some rare cases, clients with chronic illness have reported some mild healing reaction symptoms as their body releases stored toxins. Typically this is short lived and can be addressed with another coaching session or self-treatment protocol. I agree to hold harmless Stephen Daniel, the originators of Quantum Techniques, LLC, and it's practitioners, and anyone affiliated with Quantum Techniques, LLC, from any claims, liability, or loss incurred directly or indirectly by me (or anyone I may teach or seek to help using Quantum Techniques) as a result of the use or application of any techniques or methods learned from a Quantum Techniques practitioner or product. Client Request and Authorization Agreement *I Agree With The Client Request and Authorization Above.Disclaimer & Hold Harmless Agreement *I have read, understood and agree with the Disclaimer and Hold Harmless Agreement, and consent to participate in energy coaching sessions with a Quantum Techniques practitioner.Hold Harmless Agreement *I, the undersigned, request that Stephen P. Daniel, FPPR, Quantum Techniques, LLC or any other QT practitioner listed and active on the www.quantumtechniques.com website at the time of this agreement, perform an evaluation and set up sessions for the purpose of coaching me in a self-help acupressure technique for reducing stress, enhancing my health and removing any dysfunction in my bioenergetic system.Disclaimer Agreement *I understand that QUANTUM TECHNIQUES is not intended to diagnose, prescribe or treat any disease, physical or mental. They are also not intended as a substitute for regular medical or psychiatric care. I am not being advised by QT to discontinue any prescribed medication or medical or psychological care. I am hereby instructed to consult my personal physician for specific symptoms or medical concerns.Card Holder Signature * Clear Signature Bioenergetic correction is not typically a health insurance reimbursable item. Some medical savings plans do allow for these services if they are billed as acupressure for allergies or pain control. Bill my credit or debit card twice a month for the sessions provided to the client. Bill my credit or debit card for the session(s) I received. I accept that it is my responsibility to keep track of the time I use or ask the Practitioner how much time I have used at the end of each session. If you have a session with a practitioner, then an invoice will be incurred and your credit card will be charged at the end of the bi-monthly billing period during which your session occurred. Bi- monthly billing dates are always the same 1-15 Billed on the 17th. Then all sessions billed on the 16th thru last day of the month are always billed on the 2nd of the next month. Statements are sent out on the 2nd after all billing is completed You are not billed if you do not have a session with a practitioner. Submit