Session Booking

Biomagnetic Therapy consists of applying magnets on certain areas of the body in order to help balance the pH levels of alkalinity and acidity in the body. This allows the body an opportunity to naturally heal on its own. This treatment is an investment in your health, your quality of life, and your longevity.

First name

Last name

Phone Number

Date of Birth

Age

Address (Street, City, State, Zip)

Emergency Contact Name

Emergency Contact Phone

How did you hear about me?

Have you been diagnosed with a physical disease? If yes, please list:

Yes

Have you been diagnosed with a mental disorder? If yes, please list:

Yes

What health issues do you hope to address with Biomagnetic Therapy?

Have you had any accidents, injuries, broken bones, etc? If yes, please list them all by year:

Do you have any allergies? If yes, please list them all:

Please list any other health issues you currently have or have had in the past.

Are you taking any prescription medications? If yes, please list them all:

Yes

Have you had any blood transfusions or organ transplants?

Yes

Have you had Chemotherapy or Radiation in the last 13 years?

Yes

Are you scheduled to receive Chemotherapy or Radiation in the next 12 months?

Yes

Do you have a Pacemaker?

Yes

Are you or could you be pregnant?

Yes

Are you taking any nutritional supplements and/or vitamins? If yes, please list them all:

Yes

Do you follow a specific diet? If yes, for what purpose? If no, generally how do you eat?

Are you currently receiving medical treatments, alternative or holistic treatments, or any other kinds of treatments? If yes, please list them all:

What are healing approaches you have tried that have been most helpful?

What are healing approaches you have tried that have NOT been most helpful?

Are there any other concerns you think are important to your treatment?

Do you currently experience any of the following? Please check the boxes for the symptoms and conditions you have experienced in the last 6 months.

I acknowledge the following and I accept full responsibility for my health and voluntarily complete this consent and waiver of liability form.

1. I understand and acknowledge that Biomagnetic Therapy is NOT a substitute for medical care. I agree that if I have any serious medical conditions I will seek the advice of a medical doctor. I understand I should see a medical doctor for follow-up care and should view Biomagnetic Therapy care as additional therapy to the medical care provided by a medical doctor. Biomagnetic Therapy is not a substitute for physician consultation, evaluation, or treatment.

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2. I understand and acknowledge that Alison Kate is NOT a medical doctor/physician and therefore I do not view her as my physician/medical doctor. I understand and acknowledge that Alison Kate does not make medical diagnosis, does not provide medical advice or care, and does not handle medical conditions or emergencies.

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3. I understand and acknowledge that Alison Kate does not make any claims whatsoever, expressed or implied, regarding any efforts or outcomes of the sessions provided, and shall not be liable for the same.

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4. I understand and acknowledge that up to 5 days after Biomagnetic Therapy, the body starts to detoxify which may result in symptoms such as fatigue, headaches, diarrhea, and low fever amongst other like effects. This is called a healing crisis and is a natural process by which the body undergoes an intense period of cleansing and rebuilding. It is called "healing" because the body is working hard to heal itself and become stronger. This process can often be mistaken as a sickness. In fact, the reality is quite the opposite. It is a process in which the body is overcoming ill health and becoming healthier and stronger.

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Symptoms that continue beyond 7 days can be caused by reinfection and will likely need to be treated again.

5. I acknowledge and represent that I am not pregnant.

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6. I acknowledge and represent that I do not have any battery-run devices in my body such as a pace-maker or like devices that may be affected by applying magnets.

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7. I acknowledge and represent that I have not received chemotherapy and/or radiation therapy within the last 13 years from today nor have I planned one for the coming year.

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8. I acknowledge and understand that failure to disclose accurately any of the above may have serious implications. Accordingly, I understand that it is fully my responsibility to disclose pertinent information. And I accept full responsibility for my health.

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I declare that the info I’ve provided is accurate & complete

My signature below indicates that I have carefully read and reviewed this informed consent and fully understand and agree to all of the terms and conditions contained herein.

Client Signature *

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Parent/Guardian Signature (if under 18 years old)

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