Biomagnetism Therapy Intake & Disclaimer
Embodied Biofield, LLC
www.embodiedbiofield.com
embodiedbiofield@gmail.com
(570) 994-3570
Today's Date: *
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Full Name: *
Date of Birth: *
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Gender: *
Phone Number: *
Email Address: *
EMERGENCY CONTACT name, phone number and relationship to you: *
Occupation & average hours worked per week: *
Do you exercise? (Yes/No)
If yes, approximately how many hours per week?
 *
Do you have a pacemaker? *
Do you use hearing aids? *
Have you received any past or recent blood transfusion(s)? *
Have you had an organ transplant? *
Are you receiving, or have you received chemotherapy and/or radiation? (Yes/No)
If yes, please specify date and details:
 *
Do you eat fresh fruits and vegetables daily? *
Do you drink caffeine and/or alcohol? *
On average, how much water do you drink daily? *
How often do you have a bowel movement?
Do your bowel movements tend to be loose, firm, or hard to pass?
 *
How is your quality of sleep?
Do you feel well-rested when you wake up?
 *
(Women only) Currently pregnant? (Yes/No)
If yes, please specify your anticipated due date:
(Women only) Do you menstruate?
(Women only) Do you experience painful menstruation?
(Women only) Do you experience heavy menstruation?
(Women only) Do you experience painful ovulation?
Please note any other medical condition(s) or relevant information including medication(s) you're currently taking or have taken long-term in the past: *

By typing my full name below, I declare and certify my intention of receiving therapy with traditional, bioenergetic, magnetic, vibrational sound, nutritional and/or herbal modalities that may offer therapeutic benefits by supporting normal structure and function. I understand that Kristy Lee Blanco is a natural health consultant and not a licensed medical doctor or nutritionist.

Biomagnetism is based on the assumption that any medical condition may simultaneously alter the pH of two organs or two specific regions in the body. We are surrounded by magnetic fields and we also produce our own. Each cell and organ in our bodies produces a magnetic field. When this field is balanced, it helps our body function optimally. The application of magnets is done with clothes on, the client is never touched skin-to-skin, medications or any substances are not administered, no fluids or tissues are collected, and medications are never prescribed. Therefore, I understand that this is not an allopathic medical consultation. This is not a symptomatic diagnosis but an etiological analysis. I also understand that Biomagnetism Therapy may onset a powerful detox response and that the body must be well-resourced to handle any potential healing responses that may follow a session.

If I have come here accompanying a minor or a person with disabilities, I certify that I am the parent or legal guardian of said individual and that I have full capacity and authority to allow this therapy to take place.

Type FULL NAME below:

*If legal guardian signing for minor, please type "(guardian's name) for (minor's name)"

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