Bio-Resonance Client Intake Form

Name *

First Name

Last Name

Date of Birth *

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DD

YYYY

Phone number

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Emergency phone number *

Country

(###)

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Are you pregnant? *

Yes

No

Have you been fitted with a pacemaker or any electronic implants (e.g., nerve stimulators, cochlear implants, insulin pump)?

Yes

No

Have you received an organ transplant? *

Yes

No

What services are you interested in?

Bio-Resonance

MindBody Resonance

Psychotherapy

May Eugenie contact you by email with relevant updates, insights, or information about services?

Yes

No

I have reviewed information about the therapy of my choice and understand how the treatment is carried out and what it involve?. *

Yes

No

Need clarification

I understand that the Metatron Hunter bio-resonance system is used for energy testing, balancing, and supporting wellness. Any advice offered is not a substitute for medical treatment, and I am responsible for consulting a healthcare provider for any medical concerns.

I understand and agree

I understand that all remedies are made from a neutral base, such as alcohol, water, oil, or sugar pills, and are infused with the frequency patterns of substances like plants, minerals, or homeopathic remedies. These remedies do not contain any physical parts of those substances, only their energetic or vibrational imprint.

I understand and agree

I understand that my personal information and DNA sample will be used solely for treatment purposes and stored securely, either in a locked location or a password-protected system. Information about me will not be shared without my consent. DNA samples will be kept for as long as needed for my care and will be securely destroyed when no longer required or upon my request.

I understand and agree

I understand that cancellations with less than 24 hours’ notice may not be eligible for a refund.

I agree

Date *

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DD

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