Consent Form

First name

Last name

Birthday

Year

Month

Day

Address

Phone

Email

Have you ever had an organ transplant or blood transfusion?

Yes

No

If yes to organ transplant or blood transfusion, please specify

Are you pregnant?

Yes

No

Have you ever had chemotherapy or radiotherapy?

Yes

No

If yes for chemotherapy or radiotherapy, please specify:

Do you have any allergies?

Yes

No

If yes to allergies, please specify

Any known medical issues or do you wear hearing aids?

Yes

No

If yes to medical issues or hearing aids, please specify

I understand that biomagnetism is based on the assumption that medical conditions may alter the ph of two organs or specific body regions. Clients are fully clothed, no skin-to-skin contact occurs, and no substances, fluids, or medications are used. This is not a medical consultation or diagnosis but an energetic wellness analysis. I confirm then information provided is correct and that I am authorized for this therapy if signing for a minor.

I understand that all client information is kept confidential and protected in accordance with the British Columbia Personal Information Protection Act (PIPA). Information will not be shared without written consent, except as required by law.

I declare and certify my intention of receiving wellness sessions with traditional, bioenergetic, magnetic, and/or nutritional modalities that may offer therapeutic benefits by supporting normal structure and function. I understand that these sessions are not medical in nature and do not replace licensed health care treatment

I understand that services provided by 1560167 BC Ltd. (Rise and Align Holistics) may include Biomagnetism, Emotion and Body Code, Herbal and applied kinesionics and muscle testing with massage and adjustments, are complementary wellness modalities designed to support balance and optimal function. These sessions are not a substitute for licensed medical, psychological, or therapeutic treatment.

I understand that services provided by 1560167 BC Ltd. (Rise and Align Holistics) is not a licensed dietitian, physician, or mental health provider. The company does not diagnose, treat, prevent, or cure any disease or medical condition. All services are intended as complementary and educational wellness practices to support natural balance and function.

I voluntarily consent to receive services and release 1560167 BC Ltd. from all claims or liabilities arising from the use or misuse of traditional, energetic, or nutritional modalities. I indemnify and hold the company harmless from all liabilities whatsoever. PErmission is given to use anonymized data for educational purposes, provided all personal identification is removed.

Print Name of client

Print Name of Parent/ Guardian if client is under the age of 18

Signature of client or legal guardian

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Date

Year

Month

Day