Patient Consent Form

Patient Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthday*

Date of Birth

Email*

example@example.com

Biological Sex*

Marital Status:

Occupation:

Number of Children:

Referred By:

Friend, Instagram, Google, etc.

Emergency Contact*

NamePhone Number

Medical History:*

Have You Received COVID19 Vaccine?*

What is your blood type?

We will need this for the scan

List any exercise you do and how often:

If you smoke, how many times per day?

If you drink alcohol, how many times per week?

If you drink caffeine, how many cups per day?

Please list any medications and/or supplements you're taking:

Please list any family medical history such as diabetes, heart, kidney, cancer, etc. :

Please list below any surgeries, medical or metal implants, pacemakers, ectomies (organs removed), seizures:

Please list five main physical / emotional complaints in the order of importance:

By engaging in the services provided by Janine Dodge, including bio-resonance scans, Meta-Therapy, auricular therapy, custom therapeutic remedies using Structured pH Silver and imprinted frequencies, sound healing, and/or microcurrent therapy, you acknowledge and agree to the following:

Nature of Services: These services are complementary and holistic modalities aimed at supporting your body’s natural ability to achieve balance and promote overall well-being. They are not intended to diagnose, treat, cure, or prevent any specific medical condition.

Non-Substitution for Medical Care: These therapies are not a substitute for medical advice, diagnosis, or treatment provided by a licensed healthcare professional. You should continue to seek regular medical care from your primary healthcare provider or specialist.

Voluntary Participation: Participation in these therapies is entirely voluntary. You have the right to decline or discontinue treatment at any time.

Disclosure of Health Information: It is your responsibility to disclose any pre-existing medical conditions, medications, allergies, or other health concerns to ensure the therapies are appropriate for your individual needs.

Potential Outcomes: While many clients experience positive results, individual outcomes may vary, and no guarantees of effectiveness or specific results are made.

State of California Legal Notice: Under California law, these therapies are considered complementary or alternative health services. Practitioners offering these services are not licensed medical professionals unless specifically stated, and these services are provided under California Senate Bill 577, which permits alternative healing practices provided the client is fully informed and consents to the treatment.

Acknowledgment of Understanding: By signing below or proceeding with services, you confirm that you have read, understood, and agreed to the terms of this consent. You understand that the above procedures are considered to be unproven by science, but agree to allow Janine Dodge to include such in her care of me.You acknowledge that any questions have been answered to your satisfaction, and you assume full responsibility for your participation in these therapies.

Date

Patient Signature