New Patient Treatment Request Form

    Appointment Type

    First Name

    Last Name

    Street Address




    Best Phone Number to Reach You

    Your Email

    Your Date of Birth

    Your Age

    How did you hear about me?

    Appointment Date: If you need a specific day of the week or time, please let me know and I will do my best to accommodate it. We may have to push it out an extra week or two to do so. I will give you the options of my earliest availability as well your request.

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

    Tell me about any previous health issues you've had. Please be comprehensive - include allergies, operations, medical treatments, etc...

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

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

    Have you had any blood transfusions or organ transplants? YesNo

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

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

    Do you have a Pacemaker? YesNo

    Are you or could you be pregnant? YesNo

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