Pre-Treatment Form Please enable JavaScript in your browser to complete this form.This short form will collect minimal personal information along with your consent to treatment, responses necessary to create confidential patient records and provide safe diagnostic and therapeutic services conducted by Bioresonance BG. The completion of specific and more detailed questionnaires and scales will better inform our therapists and may produce a more targeted approach. Please contact us if you have any questions.Name *FirstLastEmail *Phone *Gender *MaleFemaleAre you pregnant?YesNoAge *<1818-5050Do you have a heart pacemaker? *YesNoDo you have any metal implants? *YesNoDo you have a hearing aid or cochlear implant? *YesNoHave you had any type of transplant? *YesNoWhat is the chief complaint that brought you here?Additional information or messageSigning this form indicates that you are voluntarily and with full knowledge willing to undergo a procedure referred to as BioResonance Therapy (BRT). This is a form of modern bioenergetic science. Treatment is based on bio-physics (the physics of life processes), a field of study in German and British universities that has not yet been widely applied in medicine. The human body is seen as a sea of energy. This energy is made up of electromagnetic fields consisting of physical oscillations (waveforms). These oscillations control body processes and different cells send and receive oscillations at specific frequencies (wavelengths). Neurophysiology is one area where this is recognized and many hospitals use EEG instruments, which measure “brain waves” for diagnosis. BRT is therapy with oscillations received by the BICOM instrument either from the body or from substances, such as viruses or allergens. The BICOM instrument picks up signals from the body though electrodes and returns them in a modified form. Pathological oscillations can be ‘inverted’ through a mirror circuit to reduce or even eliminate their harmful effect. The aim of BRT is to re-establish the body’s ability to regulate itself. Allergy treatment requires abstention from some foods for a few weeks. Possible reactions are tiredness and headaches, but these symptoms usually subside after a short time. As the procedure involves only the measurement of changes in the energy flow of the body with a sensitive meter, it is completely safe. The only sensation normally felt is the pressure of the electronic probe against the surface of the skin. The use of a printout recording the results makes this procedure extremely fast. At no time will the technician state or imply a client should discontinue taking any medication as prescribed by his or her physician. At no time will there be any implied or stated indication to any client to discontinue care under the direction of another physician. This procedure is not intended, implied, or stated to take the place of any conventional medical test or diagnostic procedure. At no time can this office guarantee to resolve a current health concern, however, it has been found that client compliance to the complete recommended therapy usually results in greater and more consistent changes towards better health. This office reserves the right to dismiss any client at any time due to poor compliance with the practitioner’s recommended program. I have fully read and understand the above information, the elements of my informed consent, my rights and responsibilities, and hereby give consent to the BioResonance Therapy procedure. By using this form, you agree that will store the questionnaire results for our meeting with you. You can request its deletion at any time. *I agree to informed consentBy clicking submit below, or signing the printed version, you consent to allow Bioresonance BG to store and process the personal information submitted above to provide you the content requested.SignatureClear SignatureEmailSubmit
