Energy Assessment Form
Consent to Online Energy Testing - Consent and Clinic Policy
*
Back
Next
Energy Assessment Form
The first step on your journey toward healing and well-being involves an initial assessment. This assessment begins with completing an energy assessment form, followed by an energy test to provide personalized recommendations. After the distance energy test is performed, treatment recommendations will be provided. Sometimes, these recommendations may not involve an in-person visit, which means that you won't have to start your path to addressing your health issues with a physical appointment. This process ensures an efficient and holistic approach to addressing your concerns while prioritizing your care and commitment to offering timely, effective assistance to as many individuals as possible. If this approach aligns with your needs, we invite you to take the first step on your journey with us.
Name
*
First Name
Last Name
Email
*
example@example.com
Country
*
Current country where you reside.
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number
*
Format: (000) 000-0000.
Current Issues and Concerns
*
Please describe the immediate issues you are experiencing.
Have you had any surgeries in your lifetime?
*
Yes
No
Surgeries
*
Please describe any surgeries you have had in your lifetime.
Do you take any medications or supplements?
*
Yes
No
Medications and Supplements
*
Please list all medications and supplements that you take. Include brand name if possible.
Have you had any vaccinations or shots in the last 20 years?
*
Yes
No
Vaccinations and Shots
*
Please list all vaccinations and shots you have received in the last 20 years.
Picture of You (alone, full-body, good lighting, clothed)
*
Energy Test Fee
The fee is $115 (incl. HST) and can be paid by E-Transfer or Credit Card.
Select Payment Type
*
E-Transfer. Send to gtrimarchi@innergetics.ca.
Credit Card. 3% processing fee will be added.
Submit
My Products
prev
next
( X )
Energy Test
$115.00 CAD
$
115.00
CAD
Credit Card
Should be Empty: