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
413 E Benham
Glendive Mt 59330

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