Energy Retest
Fields with an asterisk are required. All information is kept confidential.
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please describe in detail how you are feeling since completing the previous set of recommendations or receiving the Energy Healing. State any current concerns or conditions you are experiencing.
*
Have you had any surgeries in your lifetime?
*
Yes
No
Surgeries
*
Please describe any surgeries you have had in your lifetime.
Do you take any medications or supplements?
*
Yes
No
Medications and Supplements
*
Please list all medications and supplements that you take. Include brand name if possible.
Have you had any vaccinations or shots in the last 20 years?
*
Yes
No
Vaccinations
*
Please list all vaccinations and shots you have received in the last 20 years.
Energy Test Fee
The fee is $50 and can be paid by E-Transfer or Credit Card.
Select Payment Method
*
E-Transfer: Send to gtrimarchi@innergetics.ca
Credit Card
Credit Card Processing
*
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Energy Test
$
50.00
CAD
Total
$
0.00
CAD
Credit Card Information
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