Zyto Bioscan Intake Disclaimer Form

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First Name *

Last Name *

Preferred Name *

Email *

Phone *

By checking this box, I consent to receive non-marketing text messages from Living in Overflow with Earlene Bacon. Message frequency varies; message & data rates may apply. Text HELP for assistance; reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and new product updates, among others from Living in Overflow with Earlene Bacon at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance; reply STOP to opt out.

Sex *

Date Of Birth (Select year, then month and date) *

Address

Street Address *

City *

State *

Postal Code *

What Service(s) are you interested in? (Select All That Apply) *

Living in Overflow Life Coaching

Living in Overflow Business Coaching

Zyto BioScan Holistic Scan & Consultation

Living in Overflow Courses

Young Living Essential Oils & Supplements

Living in Overflow Academy & University (Coming Soon)

Who Referred You To Us?

I fully understand that Earlene Bacon is a lay Wellness ADVOCATE and TEACHER who deals strictly in helping people to improve their general health by taking steps toward freedom. These steps consist of recognizing, through discernment of the Holy Spirit, the spiritual root of an issue; taking responsibility for what I recognize; repenting to God the Father for participating with what I recognize; renouncing what I recognize; removing what I recognize; resisting what I recognized when it tries to come back; and rejoicing and thanking God the Father for setting me free and restoring others in the area that I have been freed from. Also, through better nutrition, improved lifestyle, and healthy habits such as meditating on God’s word and developing a true relationship with the Godhead, I understand that if my dis-ease or ailment is caused by a spiritual root, when the spiritual root is dealt with, the body will heal itself as God designed it to. *

I agree

I disagree

I fully understand that Earlene Bacon is NOT a licensed physician and cannot diagnose diseases, prescribe drugs, or recommend treatments for specific disease conditions. *

I agree

I disagree

I understand that all evaluations performed by Earlene Bacon or her representatives are designed to evaluate my inherent constitution and temperament for the sole purpose of helping me to improve my general health through a spiritual relationship with the Godhead and better lifestyle choices. I further understand that said evaluations cannot determine specific disease conditions I may have and do not replace the diagnostic services offered by licensed physicians. *

I agree

I disagree

I understand that Earlene Bacon neither claims nor implies that any instruction, advice, counsel, suggestions, recommendations, services, or products she or her representatives provide, whether in person or by mail or by telephone, will cure, treat, prevent, or mitigate any disease condition but are provided solely for the purpose of supporting the natural function of body systems and otherwise improving general health. *

I agree

I disagree

I understand that Earlene Bacon or her representatives will not suggest that I cease any medical care I may be currently undertaking. I understand that the decisions I make regarding my health care and the health care of those under my guardianship are my responsibility and certify that I will not hold Earlene Bacon or her representatives responsible for the consequences of my decisions. *

I agree

I disagree

I understand that Earlene Bacon believes that genuine healing comes only from God the Father and that God has provided simple and natural methods such as repentance of dead works, prayer, rest, nutrition, essential oils, herbs, and exercise to help people recover and maintain their health. I further understand that Earlene Bacon shares these methods with others as part of her God-given and constitutional rights of freedom of speech and freedom of religion. *

I agree

I disagree

Please read and sign below. Fees and payment: Zyto Bioscan is $120. Scan session time is 45 minutes max (If additional time is desired for an extended coaching session, you can pay $120 for each additional hour *A nonrefundable payment in FULL is required to book an appointment. If you are a no-show for your appointment, you will have to pay another FULL payment to reschedule. APPOINTMENT WILL BE CANCELLED IF DEPOSIT IS NOT RECEIVED 3 days prior to appointment date. Payment may be sent via Cash App ($Livinginoverflow) or Zelle (404-520-0926). Be sure to confirm Earlene's name, as she will not be responsible for money being sent to the wrong person. You may also use the next page to process your payment via debit or credit card. I have read this Disclosure Statement and Schedule of Fees and have reviewed the services offered, fees, etc. to my satisfaction and understand the foregoing and agree to the terms and conditions set therein. With this understanding, I desire to consult with him/her on my health needs. I agree to be added to Earlene Bacon's email and text list for future correspondence. I also understand that my Zyto report will be sent within 14 business days via e-mail *

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