Intake Form - Biomagnetism Therapy Center in Grand Forks, North Dakota

Client Intake Form

Biomagnetism Therapy Center Consent Form For Distance Sessions

Please fill out and submit the following form prior to your distance virtual session.

First Name *

Last Name

Email *

Cell Phone

Home Phone

When is Your Birthday?

Month

Day

Year

Street Address *

City *

State *

ZIP *

Country *

What are your main health concerns and symptoms?

Are you pregnant? *YesNoI don’t know

Do you have a pacemaker? *YesNo

Are you receiving Radiation or Chemotherapy? *YesNo

Are you taking any medication, if yes, please specify?

Consent *The undersigned acknowledges that the practitioner is not a licensed medical doctor and does not diagnose or prescribe for medical or psychological conditions nor claim to prevent, treat, mitigate or cure such conditions. The undersigned also acknowledges that the practitioner does not provide diagnosis, care, treatment or rehabilitation of individuals, nor apply medical, mental health, or human development principles, but rather provides traditional bioenergetic and magnetic modalities that may offer therapeutic benefit by supporting normal structure and function.The undersigned gives informed consent to the services that will be provided. The undersigned hereby releases the practitioner from all claims and liabilities arising from the use or misuse of traditional, spiritual, mental and bioenergetic modalities, indemnifying and holding the practitioner harmless from all claims and liabilities therefrom whatsoever. The undersigned acknowledges that a proxy will be used as a substitute if the client is unable to attend the session.