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BiomeTech is an exclusive dynamic line of wellness and regenerative products that optimize your personal health by fortifying the microbiome in your body.

The microbiome is the mechanism that signals your central nervous system (brain) and the enteric nervous system (digestion) to work effectively and optimally. It includes all of your metabolic functions, endocrine functions, autonomic functions, immune functions, and cognitive functions. The capacity of a healthy Microbiome influences every aspect of your life experience. Our goal is to assist you to optimize and maximize the capacity of your microbiome.

So that we are aware of any past and present physical aspects that make you who you are, please take time to complete the following questionnaire. Each one of these questions has meaning and is being asked for a specific purpose.

Our products can be of best service when we have a complete picture of your life, past and present. And your personal goals– small and large. Please be open and as concise as possible so that we may be able to provide you with the most support we can.

PERSONAL INFO

Who are You? The Basic 411

First Name

Last Name

Date of Birth

Gender

Birth Time

Height

Birth Place

Weight

Address

Address 2

City

State

Zip Code

Country

Phone number

Occupation

Marital/Relationship Status

Referred By (Please enter full name)

Emergency Name, Contact Number & Relationship

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CLIENT CONFIDENTIALITY AND RELEASE FORM:

I understand that LNC/BiomeTech is not a replacement for medical care. LNC/BiomeTech does not diagnose medical illness, disease or other physical or mental conditions and does not prescribe medical treatment

Confidentiality of medical and personal information obtained during the course of completing this intake and any subsequent consultations with Client Care is of the utmost importance.

I,

Name

Give my permission for LNC/BiomeTech/All employees, consultants, affiliates thereof to take notes including health history/medical and /or personal information that I choose to disclose to him/her. I understand this information may be used for the purpose of consulting with other LNC/BiomeTech Staff/Healers/Representatives for the purpose of my (the client’s ) wellbeing and/or training LNC/BiomeTech staff.

Client Signature

Type Name to Confirm

Date

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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.

What is the reason for seeking assistance from BiomeTech?

What results do you want to achieve most from using BiomeTech products?

CURRENT PERSONAL HISTORY

Let's Delve Into You

Please describe your current state of health

General: Please share your perspective of your health in as many words as you feel necessary.

Sleep: Describe your sleep patterns; share times for going to bed and waking. Do you sleep through the night? How many hours do you generally sleep? List any preferred sleep positions, body temperature in bed, dreams, nightmares, snoring, waking(s), trips to the toilet, etc. Do you wake with a good amount of energy or low energy?

Energy: Please describe your energy levels throughout the day. Do you wake up tired, or get low spots through the day? If possible, describe what time(s) you experience this.

Do you feel anxious and wired throughout the day? Do you maintain a high energy level throughout the day or does your energy wane? Do you feel productive or a lack of motivation throughout the day ? What are your peak times of productivity?

Please give your energy levels a score out of 10 (e.g. 9/10 is very high energy, or 1/10 is very low energy). Do you feel heavy-limbed, listless or fatigued at various times of the day?

How do you define stress?

Do you feel satisfied with yourself / career / life?

How would people describe you?

How would you describe yourself?

Emotionally. How would you describe yourself at the moment? Happy, sad, anxious, depressed, content? Other?

Temperament. How would you describe your temperament? Are you quick tempered? Shy? Indecisive? A People Pleaser? Self Confident? Easy Going? Keep to yourself? Life of the Party? Hyper-Critical? Detail Oriented? Passive? Aggressive? Other?

What are the most pressing challenges you are facing at this time?

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PREVIOUS & CURRENT CONDITIONS

Please see below and check all that apply

Abortion

Acne

Adenoid problems

ADHD

Allergies

Anaemia

Anxiety

Appendicitis

Arthritis (Type?)

Asthma

Backache

Bedwetting

Bleeding

Boils

Bowel Issues

Breast Issues

Broken Bones

Bronchitis

Cancer

Cataracts

Chicken Pox

Cold Sores

Constipation

Cramps

Depression

Diabetes

Diarrhoea

Eczema

Endometriosis

Epilepsy

Eyesight Problems

Fainting

Fertility Issues

Fibroids

Food Poisoning

Fungal Problems

Gall Bladder Disease

Glaucoma

Headaches

Head Injury

Hearing Problems

Hayfever

Heart Problems

Hernia

High Blood Pressure

High Cholesterol

Influenza

Hives (Urticaria)

Insomnia

Jaundice

Kidney Problems

Liver Disease

Loss of Taste

Malaria

Malnutrition

Measles

Meningitis

Menopause

Mental Health

Migraines

Miscarriage

Mumps

Nerve Problems

Ovarian Cysts

Paralysis

Period Issues

Piles

Pleurisy

Pneumonia

Pregnancy Issues

Prolapsed Uterus

Prostate Issues

Psoriasis

Recurrent Colds

Renal Stones

Rheumatism

Scabies

Sexual Issues

Sexually Transmitted Infections

Ringworm

Shingles

Sinusitis

Spleen Disease

Stroke

Teeth Issues

Throat Issues

Thrush

Thyroid Issues

Tonsilitis

Ulcers

UTI's

Vertigo

Warts

Weight Issues

Whooping Cough

Other (please specify)

Please provide further details of any of the conditions ticked above.
Details to include: the condition, age you experienced it, its duration, whether you fully recovered, medicines taken and any additional comments.

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SUBSTANCE USE (Provide Information for Each Substance Used)

DRUG CATEGORY

Age when you first used this and why

How much & how often did you use this?

How many years did you use this?

When did you last use this?

Do you currently use this?

ALCOHOL

CANNABIS
Marijuana, hashish, hash oil, CBD

CAFFEINE
Coffee, Tea, Etc.

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.*

Please Initial here:

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Full Name

Signature

Signature Date (MM/DD/YYYY)

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BiomeTech 2554 Lincoln Boulevard Suite 306, Venice, California 90291

Phone: 310.822.3801 FAX# 310.305.7287

SUBMIT

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

PERSONAL INFO

Who are You? The Basic 411

First Name

Last Name

Date of Birth

Gender

Birth Time

Height

Birth Place

Weight

Address

Address 2

City

State

Zip Code

Country

Phone number

Occupation

Marital/Relationship Status

Referred By (Please enter full name)

Emergency Name, Contact Number & Relationship

Divider Text

CLIENT CONFIDENTIALITY AND RELEASE FORM:

Name

Type Name to Confirm

Date

Divider Text

What is the reason for seeking assistance from BiomeTech?

What results do you want to achieve most from using BiomeTech products?

CURRENT PERSONAL HISTORY

Let's Delve Into You

Please describe your current state of health

General: Please share your perspective of your health in as many words as you feel necessary.

Energy: Please describe your energy levels throughout the day. Do you wake up tired, or get low spots through the day? If possible, describe what time(s) you experience this.

Please give your energy levels a score out of 10 (e.g. 9/10 is very high energy, or 1/10 is very low energy). Do you feel heavy-limbed, listless or fatigued at various times of the day?

How do you define stress?

Do you feel satisfied with yourself / career / life?

How would people describe you?

How would you describe yourself?

Emotionally. How would you describe yourself at the moment? Happy, sad, anxious, depressed, content? Other?

What are the most pressing challenges you are facing at this time?

Divider Text

PREVIOUS & CURRENT CONDITIONS

Please see below and check all that apply

Abortion

Acne

Adenoid problems

ADHD

Allergies

Anaemia

Anxiety

Appendicitis

Arthritis (Type?)

Asthma

Backache

Bedwetting

Bleeding

Boils

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.

Divider Text

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 Initial here:

Divider Text

Full Name

Signature

Signature Date (MM/DD/YYYY)

Divider Text

BiomeTech 2554 Lincoln Boulevard Suite 306, Venice, California 90291

Phone: 310.822.3801 FAX# 310.305.7287

SUBMIT

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

PERSONAL INFO

Who are You? The Basic 411

First Name

Last Name

Date of Birth

Gender

Birth Time

Height

Birth Place

Weight

Address

Address 2

City

State

Zip Code

Country

Phone number

Occupation

Marital/Relationship Status

Referred By (Please enter full name)

Emergency Name, Contact Number & Relationship

Divider Text

CLIENT CONFIDENTIALITY AND RELEASE FORM:

Name

Type Name to Confirm

Date

Divider Text

What is the reason for seeking assistance from BiomeTech?

What results do you want to achieve most from using BiomeTech products?

CURRENT PERSONAL HISTORY

Let's Delve Into You

Please describe your current state of health

General: Please share your perspective of your health in as many words as you feel necessary.

Energy: Please describe your energy levels throughout the day. Do you wake up tired, or get low spots through the day? If possible, describe what time(s) you experience this.

Please give your energy levels a score out of 10 (e.g. 9/10 is very high energy, or 1/10 is very low energy). Do you feel heavy-limbed, listless or fatigued at various times of the day?

How do you define stress?

Do you feel satisfied with yourself / career / life?

How would people describe you?

How would you describe yourself?

Emotionally. How would you describe yourself at the moment? Happy, sad, anxious, depressed, content? Other?

What are the most pressing challenges you are facing at this time?

Divider Text

PREVIOUS & CURRENT CONDITIONS

Please see below and check all that apply

Abortion

Acne

Adenoid problems

ADHD

Allergies

Anaemia

Anxiety

Appendicitis

Arthritis (Type?)

Asthma

Backache

Bedwetting

Bleeding

Boils

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.

Divider Text

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 Initial here:

Divider Text

Full Name

Signature

Signature Date (MM/DD/YYYY)

Divider Text

BiomeTech 2554 Lincoln Boulevard Suite 306, Venice, California 90291

Phone: 310.822.3801 FAX# 310.305.7287

SUBMIT

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