BIOFIELD HEALING MALLORCA Client Intake Form & Disclaimer PRACTITIONER: G. Robinson A. Personal Information Full Name Date of Birth Cell Phone Email Address City/Province State/Region Post Code Country B. Health History Please check all that apply and provide additional information if needed. Pregnancy or planning to become pregnant Cancer or terminal illness Heart condition/Pacemaker Concussion or head injury in last 6 months Currently taking medications Other condition If 'Other' or details needed, please describe: List goals for today and long-term health: C. Client Consent & Agreement I grant my practitioner permission to use light touch and weighted forks on my body's biofield. I may revoke this permission at any time. Client Signature (Typing name = legal signature) Date Signed Submit Intake Form