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MBS Therapies
Health Information, Waiver & Disclaimer
First name
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Last name
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Multi-line address
Country/Region
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Address
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City
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Zip / Postal code
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Email
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Phone
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Birthday
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Month
Day
Year
What symptoms are you experiencing?
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When did these symptoms begin?
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Which treatments have you experienced?
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Reiki
Reflexology
Acupressure
Ear Seeds
Moxabustion aka Moxa
Ear Candling
Sound Therapy
Aromatherapy
Ceremonial Cacao
Hape (Shamanic Snuff)
Sananga (Shamanic Eye Drops)
Ayurveda
Yoga Asana (postures)
Breathwork
Meditation
Earthing/Grounding
Other treatments, modalities or plant medicines. Briefly describe.
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Any current or prior physical health and/or mental health conditions/diagnosis'?
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Which pharmaceutical medications, if any, do you consume? How much? How often? Please describe.
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Which supplements, if any, do you consume? How much? How often? Please describe.
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Additional information:
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Date
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