Biomagnetic Energy Session Consent I declare and certify my intention of receiving an energy session with traditional, bioenergetic, magnetic and/or nutritional modalities that may offer therapeutic benefits by supporting normal structure and function. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Age * Gender * Phone Number (###) ### #### Cell Number * (###) ### #### Email * How did you hear about biomagnetism? * Occupation * How often do you exercise? * Do you have a pacemaker? * Yes No Do you use hearing aids? * Yes No Do you drink enough fluids? * Yes No Have you ever been transfused? * Yes No Have you ever received an organ? * Yes No Do you eat fruits/vegetables? * Yes No How are your bowel movements? * How is you sleep? * Are you or have you been under chemotherapy and/or radiotherapy? * Yes No Any other medical conditions or meds regularly taken? * Biomagnetism is based under 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 bodies function optimally. The application of magnets is done with clothes on, the client is never touched skin to skin, meds or any substances are not administered, no fluids or tissues are collected, and meds 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 Nadia Martinez is NOT a doctor and does not claim to diagnose, treat or cure any medical condition. If I have come here accompanying a minor or a person with disabilities, I certify that I am the father, mother, or legal tutor of said person and that I have full capacity and authority to allow this therapy. Permission is given to use any information about me for research and publication so long as all personal identification is masked. Electronic Signature * Please provide your full name. Date * MM DD YYYY Thank you!
