Client Intake Form

Please complete the following information prior to your session. Our device locates your unique energy frequency using this specific information. All data is kept strictly confidential.

If you have any questions, email me (sue@planetbioscan.com) or give us a call at 480-907-6930.

First Name:

Middle Name:

Maiden Name (if applicable):

Last Name:

Address:

City:

State:

Zip:

Telephone Number:

E-Mail:

Date of Birth (including year):

City and State of Birth:

Country of Birth (if not USA):

Do you have a pacemaker?
Yes
No

If female, are you pregnant?
Yes
No

What is the main goal you wish to achieve via your quantum biofeedback sessions
with Planet BioScan?

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