Informed Consent for Therapy Conducted by Anna Bartoszewicz

• I voluntarily agree to undergo bioenergy therapy carried out in accordance with the principles outlined on the website www.annabarto.life
• I understand that the therapy consists of 4 sessions — one session per day over 4 consecutive days, with each session lasting between 15 and 40 minutes.
• In the case of remote sessions, I always choose a safe location for myself, away from bodies  of water.
• I understand that I may interrupt a session or discontinue the therapy at any time without giving a reason.
• I have read and understood the information provided on www.annabarto.liferegarding how  to prepare for a session, what to expect during and after a single session and the entire course of therapy, as well as the suggested timeframe for undergoing another course of therapy.
• I understand that I may request additional information about my therapy at any time.
• Before and during the therapy, I voluntarily provide accurate information about my current health condition and willingly send my photographs, which will be used solely for the purpose of my therapy.

☐ Dizziness   (I easily lose balance)
☐ Osteoporosis
☐ Spinal injury
☐ Severe body pain
☐ Epilepsy
☐ Pulmonary fibrosis

☐ Emphysema
☐ Silicosis
☐ Asbestosis
☐ Sarcoidosis
☐ Alzheimer’s disease
☐ Severe memory loss

☐ Facial   nerve paralysis (*Paresis Facialis, *Paresis Trigeminus)

☐ Inflammation on the body, upper or lower limbs – please state the diagnosis:

……………………………………………………………………………………………………………………..

First Name:

Surname:

Preferred contact method (phone number, WhatsApp, Skype, Messenger): 

Date:

Signature: