IMPORTANT NEW CUSTOMER INFORMATION, PLEASE FILL AND SUBMIT BELOW!
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CONTACT INFO
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**To select your birth year, click on the current year located above the calendar.**
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INTRODUCTION

Our questionnaire is designed to get to know you and better understand your goals and desires for using Biometech products. The more information you provide, the better we will be able to customize your program to fit your needs. 

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HEALTH

Which of the following do you consume regularly:

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Have you ever taken the following medications:

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WELLNESS
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WELLBEING
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GOALS & DESIRES

Please answer the following questions. Go as in depth as you feel comfortable:

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We at BiomeTech believe it is every person’s divine right to live in Prosperity- Emotionally, Financially and Health-fully. In this way, we can work in partnership to improve your health.

By signing and initialing below: You, the client, understand that when beginning this program and making changes in your nutritional and/or dietary habits, you may experience a period of detoxification.  If symptoms arise and you need assistance with your spray program or if you have questions, please call our office for assistance.

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Possible Detoxification Symptoms Could Be:

Irritability, restlessness, fatigue, listlessness, bad dreams, bloating, nausea and flu like symptoms.

You may also experience a release of repressed emotions such as anger and sadness.

These are normal Detox Symptoms and they will pass as you continue you program.

Please also note that this information and any accompanying printed material is not intended to replace the attention or advice of physicians or other healthcare professionals. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with a qualified health care professional.

DISCLAIMER *The statements made regarding these products have not been evaluated by the Food and Drug Administration. The efficacy of these products has not been confirmed by FDA-approved research. These products are not intended to diagnose, treat, cure or prevent any disease. All information presented here is not meant as a substitute for or alternative to information from healthcare practitioners. Please consult your healthcare professional about potential interactions or other possible complications before using any product. The Federal Food, Drug, and Cosmetic Act requires this notice.*
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BiomeTech 2554 Lincoln Boulevard Suite 306,   Venice, California 90291  

Phone: 310.822.3801   FAX# 310.305.7287


Thank You For Completing This Form. All Information Is Confidential. 
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