Name *

First Name

Last Name

blood group *

O-

O+

A-

A+

B-

B+

AB-

AB+

unknown

Date of birth *

MM

DD

YYYY

Time of Birth *

Hour

Minute

Second

AM PM

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Check those which apply *

Tuberculosis Chronic Bronchitis

Emphysema

Chronic cough

Asthma

Lung cancer

Heart Attack

Angina pectoris

High Blood Pressure

Hypothension

Brain hemorrhage

Brain aneurysm

Alzheimer

Senile dementia

Epilepsy

Convulsions

Parkinson

Deafness

Blindness

Varicose veins

Hemorrhoids

Arterial insufficiency

Venous insufficiency

Diabetes

Hypothyroidism

Goiter

Breast cancer

Cervical uterine cancer

Prostate cancer

Leukemia

Lymphoma

Stomach cancer

Colon cancer

Melanoma

Other kind of cancer

Kidney insufficiency

Kidney stones

Mental disturbance

Schizophrenia

Depression

Bipolarity

Neurosis

Hiatal hernia

Diverticulosis

Other

Have you suffered from any of these illnesses? *

Rubeola

Measles

Varicela

Scarlatina

Mumps

Hepatitis

Exanthema

Frequent angina

Sinusitis

Allergic rhinitis

Asthma

Other

Date of last period (m/d/y)

MM

DD

YYYY

*

I understand and accept that by checking the box and typing my name in the Electronic Signature Field I am giving Patient Acknowledgement and Consent that the Diagnostic Study performed by Quantum Diagnostics with Molecular Low Frequency Resonance Technology is part of a therapeutic procedure considere an alternative or complimentary therapy and that it is always a compliment and not a substitute for conventional medicine.

Electronic signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Choose your preffered Date *

MM

DD

YYYY

Choose a secondary Date *

MM

DD

YYYY

Disclaimer *

understand this are tentative dates and that they may not be available. I understand that a memeber of Renovatium will contact me to give me an appointment.

Name *

First Name

Last Name