IMPORTANT NEW CUSTOMER INFORMATION, PLEASE FILL AND SUBMIT BELOW!

CLIENT INFORMATION

First Name

Last Name

Cell

Office Phone

Fax

Date, Time, Place of Birth

Occupation

Partner Name & Contact Number

Address

Address 2

City

Zip Code

Country

HISTORY

Referred By

Date of Initial Visit

Describe your health challenges, physical & emotional history

What are your physical and emotional goals?

DO YOU?

Do You Drink Alcohol? - If yes, how much and how frequently?

Do You Use Caffeine? - Yes or No

Do You Use Sugar? - Yes or No

Do You Use Aspartame, fake sweeteners, etc.? - Yes or No

Do You Use Marijuana/CBD oil? - Yes or No

Do You Smoke Cigarettes? - Yes or No

Do You Use Recreational Drugs? - Yes or No

If yes, what's your favorite drug?

Do You Use Prescription Drugs? - Yes or No

If Yes - Prescriptions - Which ones, how much, how frequently?

Do you now, or have you suffered from depression? Please describe.

Do you have trouble sleeping through the night? - Yes or No

Do you have trouble waking up? - Yes or No

Have you ever taken Accutane? - Yes or No

Have you ever taken Larium? - Yes or No

Have you ever taken Retin-A? - Yes or No

Have you ever taken Phen Phen? - Yes or No

Have you ever taken steroids? - Yes or No

Have you ever taken any of the following benzodiazepines? If Yes, which ones? (Xanax, Valium, Lexotan, Librium, Klonopin, Tranxene, Rohypnol, ProSom, Dalmane, Paxipam, Ativan, Serax, Doral, Halcion)

Divider Text

We, at BiomeTech, believe it is every person’s divine right to live in Prosperity- Emotionally, Financially and Health-fully. In this way, we can work in partnership to improve your health.

By signing and initialing below: You, the client, understand that when beginning this program and making changes in your nutritional and/or dietary habits, you may experience a period of detoxification. If symptoms arise and you need assistance with your spray program or if you have questions, please call our office for assistance.

Divider Text

Possible Detoxification Symptoms Could Be:

Irritability, restlessness, fatigue, listlessness, bad dreams, bloating, nausea and flu like symptoms.

You may also experience a release of repressed emotions such as anger and sadness.

These are normal Detox Symptoms and they will pass as you continue you program.

Please also note that this information and any accompanying printed material is not intended to replace the attention or advice of physicians or other healthcare professionals. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with a qualified health care professional.

DISCLAIMER *The statements made regarding these products have not been evaluated by the Food and Drug Administration. The efficacy of these products has not been confirmed by FDA-approved research. These products are not intended to diagnose, treat, cure or prevent any disease. All information presented here is not meant as a substitute for or alternative to information from healthcare practitioners. Please consult your healthcare professional about potential interactions or other possible complications before using any product. The Federal Food, Drug, and Cosmetic Act requires this notice.*

Please Initial here:

Divider Text

Full Name

Signature

Signature Date

Divider Text

BiomeTech 2554 Lincoln Boulevard Suite 306, Venice, California 90291

Phone: 310.822.3801 FAX# 310.305.7287

The 5% discount will be processed or refunded once an order is placed!

SUBMIT

Thank You For Completing This Form. All Information Is Confidential.