New Client Intake Form

Please fill out this form before your appointment

First Name

Last Name

Date of Birth

Describe the symptoms you are currently experiencing

Are you currently under a Medical Doctor or other practitioner’s care for a specific health issue? If so, what treatments are you undergoing?

Do you have any allergies / electronic implants e.g. pace maker / have you had chemotherapy or radiotherapy?

Faye Coulson has been Certified to provide BioMagnetism Therapy by the ESCUELA SUPERIOR DE BIOMAGNETISM MEDICO ISAAC GOIZ DURAN and Dr. Isaac Goiz Duran, * She is not a Medical Doctor, she is not making a medical diagnosis or providing medical advice or care, * I should see a Medical Doctor for follow-up care if needed, and I should view BioMagnetism Therapy care as additional therapy to the medical care provided by a medical doctor. Biomagnetism Therapy is not a substitute for Physician consultation evaluation, or treatment.

Signature (or parent/guardian if under 18)

Date

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