Please fill out the below forms and return it to our email and send a picture of the subject receiving the treatment to our Whatsapp 646-377-0448.

"AllerGtox"

Bionetic Stress Assessment and Self-Regulation Counseling Authorization and Release Form

The Bio-Responses and Stress Point measurements taken during the Assessment session used by the Therapist, measure the electrical responses and energy flows of the body, aiding to identify various stressors that might impede the energetic and regulatory processes. The evaluation may include recommendations for natural remedies, exercise, stress reduction, detoxification, and/or nutritional changes designed to balance the energy meridians and enhance overall metabolism. The assessment process and related recommendations are not cures for any known diseases, nor have they been proven clinically to eliminate, prevent, or mitigate any specific disease process.The Bionetic Stress Assessment is not a method of diagnosing, or treating diseases, nor are the suggested remedies designed to replace any of the medications or treatments that the Client is currently advised to take by a primary care practitioner.

 

1. I fully understand that the attending consultant is not an allopathic doctor (M.D.) and does not pretend to be, but is a holistic Bionetic practitioner providing services that are not allopathic, but that are within the parameters of a natural health, physiology enhancement, energetic health, and wellness philosophies.

 

2. I fully understand that the attending consultant does not offer allopathic drugs, surgery, chemical stimulants or radiation therapy, or mitigation of disease processes, but is providing information and natural products to restore natural balance and optimum conditions for optimal physiological performance.

 

3. I fully understand that the consultant is not diagnosing or treating any illness or disease, but is assessing only the Bio-Energetic balances and overall stress-point responses of the body, and that these services may not be generally accepted and/or recommended by allopathic physicians or other licensed health professionals.

 

4. I fully understand that the attending consultant IS NOT encouraging me to terminate or modify any previous or ongoing medications under the direction of any licensed practitioner, and that the attending consultant can/will not dissuade me from seeking allopathic treatment from a licensed practitioner.

 

5. I presently seek consultation, advice, opinions and/or programs, tests, assessments and/or products within the scope of the attending consultant's practice based upon the principles of holistic Bio-Energetic health and have solicited the attending consultant's services in good faith, exerting my free will and following the dictates of my own conscience which allows me to select what I understand is most beneficial in optimizing my body’s metabolic function and enhancing my wellbeing.

 

6. I take full legal and total responsibility for any minor or incompetent accompanying me.

 

7. I authorize the attending consultant to provide their services to me on my behalf, and hereby release them from any and all claims and potential claims arising from my actions or failure to act upon their advice.

 

8. I give full faith that I have read and understand this document entirely, that I have received a verbal explanation of the same from the attending consultant and/or that he/she has answered satisfactorily all of my questions regarding the information on this document.

 

9. I am willing to declare under oath all of the above statements by request of the attending consultant.

 

I hereby consent to and authorize the above described evaluation and consultation:

 

Thanks for submitting!

Client Allergy Questionaire
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Please fill out the following form to help us understand your condition.

Gender

 

Although your history and symptoms are very important in our analysis of your condition, it is also important for us that you understand:


⦁    We do not treat symptoms or diseases.
⦁    We do not treat allergies but sensitivities and intolerances.
⦁    A symptom is an attempt by your body to tell you something.
⦁    We will attempt to find the underlying cause.
⦁    This program uses homeopathic and energetic remedies rather than pharmaceuticals.
⦁    There is no single “healthy” diet that will work for everyone.
⦁    Just because food is considered “healthy”, does not mean it is “healthy” for you.
⦁    Your diet consists of everything you eat, drink, rub on your skin, or inhale.
⦁    Our procedures are safe and painless.

Briefly describe the reason for your visit and what you hope to accomplish:                     
                                                            
 

AGE WHEN SYMPTOMS WERE FIRST OBSERVED
PREVIOUS DIAGNOSIS OF ALLERGY OR SENSITIVITY
FAMILY MEMBER SHOWING ALLERGIES OR SENSITIVTY
FREQUENCY & SEVERITY OF SYMPTOMS
SYMPTOMS ARE WORSE
SYMPTOMS ARE BETTER
ANIMALS, INSECTS AND BIRDS THAT CAUSE SYMPTOMS ON EXPOSURE
FOOD RELATED SYMPTOMS
FOODS THAT CAUSE SYMPTOMS FROM ONE HOUR TO THREE DAYS AFTER EXPOSURE
CHEMICALS THAT CAUSE SYMPTOMS
WHEN ARE YOUR SYMPTOMS WORSE
MEDICATIONS (Do you take any of the following medications on a regular basis?)
Does anyone smoke in your home?
Have you ever seen an allergist?
Have you had allergy skin testing?
Did you have any positive reaction?
Have you ever received allergy injections?
Are you exposed to chemicals or strong odors at work?
Are you symptoms worse while at work?

Thanks for submitting!