Detox Registration Form - HEALING WITH ENERGY

Our Detox is administered remotely via Quantum Engtanglement on the Spooky2 Rife technology.
I aim to respond to you within 48 hours to confirm your place on your desired 11-Day Terrain Detox date.

Please make sure you have read our FAQs page & Terms & Conditions. If you feel we have missed something, please don’t hesitate to get in touch with Amy at welcome.healingwithenergy.co.nz

For under 16 year old participants: Parents please fill out the care givers information at the bottom of the form.

The Finer Detail: No personally identifiable information will be shared anywhere. Information is collected

from 2 x Feedback forms – we will email you the links (one prior to detox commencing and one 3 weeks after the detox has finished). The information in these forms is collated to help others make health decisions in the future around what Rife treatments might help them. Your DNA will be destroyed on completion of the detox (unless we have prior communication that you are trying another treatment). Please remember that providing personal information is entirely optional and I encourage you to only share what you are comfortable with.

11-Day Terrain Detox Registration Form

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Name

First

Last

Age of participant

Phone (Parents phone number if under 16 years)

Your Location (Town/City)

Choose 11 Day Terrain Detox date you would like to join:

Do you have Mercury/Amalgam fillings in your teeth?

We will make sure you are put in the right detox for you

I understand it is recommended I drink plenty of filtered/still mineral water for the time of the detox

Read our FAQs for more information

I understand it's recommended I take a supplement to keep my bowels moving during detox - if NOT going every day naturally

Read our FAQs for more information

I understand it's recommended I take a supplement to help absorb toxins if I suffer from Herxheimer reaction

Read our FAQs for more information

How is your general health? Are you looking to address anything specific?

Caregivers Name (if participant under 16yrs)

First

Last

Caregivers Email (if participant under 16yrs)

Caregivers Phone (if participant under 16yrs)

Do you agree to fill out a 11 Day Terrain Detox Feedback Form, 3 months after your treatment is complete?

Sample of form in the footer of website under 'communication'

Terms & Conditions

Please tick to confirm you have read our Terms & Conditions

Terms & Conditions can be found in the footer of website under 'information'

Nail sample receipt agreement

I understand it is my responsiblity to get the nail sample to the address supplied a day before the treatment starts. (Address will be sent upon receipt & acceptance of your registration)

Our Detox is administered remotely via Quantum Engtanglement on the Spooky2 Rife technology. I aim to respond to you within 48 hours to confirm your place on your desired 11-Day Terrain Detox date.

11-Day Terrain Detox Registration Form

Our Detox is administered remotely via Quantum Engtanglement on the Spooky2 Rife technology.
I aim to respond to you within 48 hours to confirm your place on your desired 11-Day Terrain Detox date.