Client Follow Up Form / Consent

Client

FOLLOW UP FORM

and

Informed Consent

Do not use this for INITIAL BioEnergetic Scan Services. ONLY for follow-up

FOLLOW UP FORM AND CONSENT FOR BIOENERGETIC SERVICES

I am filling out this form for: *

Myself as client Minor child who I am legally allowed to consent for As a practitioner ON BEHALF OF MY CLIENT. I will upload a HARD COPY of my clients consent to BAR LLC Other: please email a hard copy of client consent to info@bioenergeticanalysisresources.com

* Indicates required field

Name *

First

Last

Date of Birth *

Tell us about your saliva swab (biological sample) *

My practitioner is sending it to you I am sending it to you I am ok to proceed without a biological sample

Practitioner's Name and/or Office Name *

Briefly Describe what has changed? What has improved? What has not improved? Has anything worsened? Any new concerns etc..... *

Mailing address for SALIVA SWAB if you or your practitioner are sending one. Please swab the inside of your cheek with a clean cotton swab (a q-tip is fine) and place in a ziploc bag with
1. your name
2. your practitioner name/office name
3. PRACTITIONER EMAIL (NEW!!! Please include on ziploc bag or envelope)
4. your (client) date of birth.

Practitioners: we will now be notifying you by EMAIL when your client sample has arrived at the home office for testing.

Mailing address for SALIVA SWAB.

BAR, LLC
2810 Swanson Road
Nekoosa WI 54457

UPDATE Biological samples are not required at this time if you wish, we will work off your energetic signature of your name, date of birth and location in the world. If you would like to send a biological sample you may send your choice of a saliva swab, a hair sample, or nail clippings, but it is not required.

READ IN FULL HERE THE CLIENT INFORMED CONSENT Consent Form

I AFFIRM I HAVE READ IN FULL THE CLIENT INFORMED CONSENT AND DISCLOSURE PROVIDED IN THE FIELD ABOVE *

YES

TYPE YOUR FULL NAME BELOW. THIS WILL SERVE AS YOUR ELECTRONIC SIGNATURE FOR CONSENT FOR BIOENERGETIC SERVICES. Type ONLY YOUR NAME in the box below. If you are filling out the form for someone else unless you are the parent of a minor, legal guardian, or POA, please email a hard copy of the client consent with the client's signature to info@bioenergeticanalysisresources.com *

Submit

ClientFOLLOW UP FORMand​Informed Consent

Do not use this for INITIAL BioEnergetic Scan Services. ONLY for follow-up

​FOLLOW UP FORM AND CONSENT FOR BIOENERGETIC SERVICES

Client

FOLLOW UP FORM

and

Informed Consent

FOLLOW UP FORM AND CONSENT FOR BIOENERGETIC SERVICES