BIOMAGNETISM WITH FAYE
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New Client Intake Form
Please fill out this form before your appointment
First Name
Last Name
Email
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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