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

* 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

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 *

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