Bioresonance Intake Form

Full Name *

Street Address *

City, State, Nation *

Postal Code *

Email Address *

Phone Number *

Birthdate *

Check One *

Male

Female

Height *

Weight *

Indicate if you are overweigh/underweight or ideal: *

How were you referred *

Date nails were cut *

Please list any organs you have had removed - including teeth *

List of Medications Currently Taking *

Please list any supplements you are currently taking *

Type of Water Drank *

Amount of Water Consumed Each Day in Ounces *

# of alcoholic drinks per day on average *

# of cups of Coffee, tea or caffeine Products per day *

Number or sugar type products consumed per day (including soda, ice cream etc.) *

Personal Stress 1-10 (10 max) *

Main Sources of Stress *

Time You Go to Bed *

Avg # Hours of Sleep per night *

Are you sensitive to the environment, taking supplements, medications or other sources: If yes include details: *

How would you rate your overall Health on a scale of 1 – 10 with 1 very Poor and 10 being excellent *

Please list the ONE major health issue you are experiencing that you feel is the MOST Important *

Please list specific issues you are experiencing and place a star * in front of the issues that are the most important to you *

READ AND INITIAL BELOW: Note that Bioresonance focuses on the system that is the most stressed as determined by a full body scan. It is recommended that this system receive therapies for 4 to 6 weeks. Along with this approach, I may help you with one other issue that you consider to be the most important. Please note that applying therapy to “everything” all at once is not recommended. This is a process. The basic rule of thumb is that for every year you have been ill, you need a month of therapy. As with all my programs, this helps the body heal from the inside out. *

READ AND SIGN BELOW: Wellness & Bio-Feedback Research and Training Consultation Waiver 1. I fully understand that Doreen McCafferty is not an allopathic practitioner and does not portray herself as one but is a wellness consultant and Bio-Feedback technician. 2. I fully understand the difference between the practice of allopathic (conventional) medicine, nutritional wellness consulting, and bio-feedback. 3. I fully understand that the services provided by Doreen McCafferty are not allopathic, but are strictly behavioral, stress or bio-feedback in nature. 4. Any reference to patient within this frequency balancing is solely due to the technical terminology within the Oberon program and in no way implies that the client is a medical patient. 5. I fully understand that Doreen McCafferty performs her services within the parameters of a natural health care and wellness system using bio-feedback and stress reduction. 6. I fully understand that Doreen McCafferty does not offer allopathic drugs, surgery, chemical stimulants, radiation frequency balancing, or any other conventional treatments. In addition, she does not diagnose, treat, or otherwise prescribe for any disease, condition, or illness and that my wellness and stress parameters are being measured. 7. I have solicited Holistic Wellness from Within LLC and Doreen McCafferty’s services in good faith, exercising my free will and following my dictates of my own conscience which allows me to select what I understand is most beneficial to my health. 8. I also exercise my free will in asking Holistic Wellness from Within LLC and Doreen McCafferty for her opinion on items and situations which may expedite my good health; it is my choice should I accept to utilize or apply any of those ideas or suggestions at any time. 9. If I desire any services not provided by Holistic Wellness from Within LLC, which is my prerogative, I fully understand that I should seek them elsewhere. 10. I presently seek counsel, advice, opinions, bio-feedback, or points of view and/or programs within the scope of Holistic Wellness from Within LLC and Doreen McCafferty’s wellness and stress reduction practice. I am fully aware and release Holistic Wellness from Within LLC and Doreen McCafferty to do bio-feedback stress interpretations and frequency balancing. 11. I fully understand that the services provided by Holistic Wellness from Within LLC and Doreen McCafferty are not generally accepted and/or recommended by allopathic doctors (MD’s) or other conventional health care professionals. I realize that insurance payments are not accepted for bio-feedback services from Holistic Wellness from Within LLC. 12. I understand that payment is expected prior to receiving service, unless otherwise arranged prior to my scan. 13. I understand that no refunds are issued for bio-feedback services. 14. By signing below, I acknowledge that I have read and understand all parts of this waiver and that I have had the opportunity to ask any questions with regards to all such procedures. 15. The Food and Drug Administration have not evaluated these statements. This product is not intended to diagnose, treat, cure or prevent any disease. 16. I understand that it is my responsibility to present myself when observing or requesting scans and services, including bio-feedback, from Holistic Wellness from Within LLC, when employed by the FDA or any other governmental agency. SIGN BELOW *

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