Your Email (required)

Patient's Full Name

Preferred First Name

Your Gender
MaleFemale

Date of Birth

Your Age

Mailing Address, City, State, Zip

Best Phone Number

Occupation

Employer

Employer Phone

Marital Status
SingleMarriedWidowedDivorced

Name of Spouse

Names and ages of Children living with you

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship to you

Have You Visited our Website?
YesNo

Whom may we thank for referring you?

Would you like Dr. Smith to pray for you before your treatment?
Yes, pleaseNo, thanks

Tell us about your symptoms.

Please describe your symptoms in detail:

Please list anything that you believe you are allergic or sensitive to:

What allergies or sensitivities have been confirmed by any type of testing?

How long have you had your symptoms?

How severe are your symptoms?
MildModerateSevere

What doctor-recommended treatment(s) have you had in the past?

Were they effective?
YesNo

If yes, which ones?

Please list all over-the-counter and prescription medications that you are taking and what they are for:

What nutritional supplements are you taking?

Have you ever had a life-threatening allergic reaction?
YesNo

If yes, to what?

Do you have any of the following?
Celiac DiseaseLiver ProblemsWeak Immune SystemLyme Disease Adrenal ExhaustionCandida

Do you have recurring:
Yeast InfectionsAthletes FootNail Fungus

Do you have chronic:
FatigueMemory ProblemsDepressionHeadaches

Please rate your overall energy level:
poorfairgoodexcellent

Please rate your overall physical health:
poorfairgoodexcellent

Please rate your current stress level:
normalhighintolerable

Do you have:
AsthmaSneezingSinusitisWatery, Itchy, Swollen Eyes

Do you get bacterial infections in your:
SinusesLungsEars

Do you frequently get colds?
YesNo

What pets or animals do you have?

Do fragrances, chemical odors, or second-hand smoke irritate your sinuses or lungs?
yesno

Do you inhale chemical odors or other fumes on a regular basis?
yesno

Do you or your spouse use a down/feather pillow or comforter?
yesno

Has there been any new painting, carpeting, etc. at your home or office during the past 6 months?
yesno

Are your symptoms worse when you clean the house or garage?
yesno

Do your symptoms wake you up at night?
yesno

Are your symptoms worse when you wake up in the morning?
yesno

Are your symptoms worse in the:
springsummerfallwinter

Are your symptoms worse when you are:
indoorsoutdoors

Are your symptoms worse at:
homework

Do you have:
IndigestionBloatingDiarrheaConstipation

Do you get:
Skin RashesItchingHivesEczemaHeadaches

After eating, do you ever feel:
StimulatedHyperactiveFatigued

Do you take antacids or acid blocking medication?
yesno

Please list any food or beverages that seem to cause any unpleasant symptoms:

What specific food items do you frequently eat for breakfast, lunch, dinner or snacking?

What food or beverages do you crave?

Which of these do you drink on a regular basis?
CoffeeTeaMilkFruit JuiceSoda PopDiet Soda PopBeerWineSoy MilkRicemilk

Have you had any root canals?
yesno

If so, how many?

Are you wearing a pacemaker?
yesno

Please read the following completely, then enter your name at the very bottom.

OFFICE PROCEDURES AND FEES

Thank you for choosing CranioBiotic Technique (CBT). This revolutionary, all-natural healing system was developed in 2002 by Dr. Anthony Smith. You will be joining the many thousands of people from around the world who have experienced the extraordinary healing power of CBT.

Your CBT examination is designed to identify many possible causes of inflammation, toxicity or dysfunction. This examination utilizes Muscle Response Testing (MRT). With MRT, a strong muscle will weaken when the patient touches a specific substance, or when the doctor touches a reflex point that indicates the presence of a specific “health stressor”.

CBT treatment involves the stimulation of specific points on the upper body, while a gentle magnetic field is applied to the brain. This relatively simple but powerful technique takes less than a minute to perform for each specific procedure.
It is a good idea to have a brief re-exam about one to three months after your last treatment. If any of your previous procedures were ineffective, they will be re-treated at no charge.

CBT FEES

Consultation and Comprehensive Exam: $250

Allergy Treatment: $40 for each allergy (includes any necessary re-treatment for life)

All Other Procedures: $40 (for each specific treatment)

Brief Re-examination: $60

The total fee is typically between $400 and $900, depending on how many procedures and nutritional supplements are necessary. Payment in full is expected at time of service. We only accept cash, checks, Visa, MasterCard, American Express and Discover.

Informed Consent Agreement (CBT)

I hereby request that Dr. M. Anthony Smith evaluate and treat me (or my dependent) with CranioBiotic Technique (CBT), hereafter referred to as CBT.

I understand that CBT techniques and procedures are not medical diagnostic procedures, and that a definitive medical diagnosis of allergens, infectious agents, toxins, parasites, and biochemical dysfunctions may require specific objective medical laboratory testing procedures, for which CBT techniques are not substitutes. Instead, the purpose of the CBT evaluation is to determine how your nervous system perceives those types of issues. CBT treatment then attempts to optimize your immune system’s recognition of those problems so that it can effectively correct them.

I understand that CBT utilizes Muscle Response Testing, like many medical testing procedures, is not 100% accurate. I also understand that the CBT techniques and procedures that are utilized in evaluating, investigating, examining or treating include the use of magnets, energetically-imprinted test vials, manual therapy, nutritional therapy and acupuncture-like points on the body.

I also understand that the results of medical lab testing may differ from the results of CBT evaluations. I also understand that other types of care are available for my health problem(s).

I understand that the results and benefits of CBT are not guaranteed, and that some people do not benefit from them. I also understand that my symptoms will improve only if the cause(s) of those symptoms are successfully identified and corrected with CBT procedures.

I understand that CBT is not an effective treatment for life-threatening (anaphylactic) allergies, and that I must never expose myself to life-threatening allergens. I also understand that CBT is not a method of diagnosing or treating cancer, and that medical oncologists are the only doctors who are qualified to perform those procedures.

The CBT treatment has been explained to me, and I understand that certain immune responses or detoxification symptoms may result from my treatment. These may include, but are not limited to: fatigue, fever, chills, nausea, headache or body aches.

I understand that I am prohibited from receiving treatment with magnets if I have a heart pacemaker.

I understand that if any unexpected flare-up of my symptoms should occur, I am responsible for obtaining appropriate medical care for those symptoms.

I understand that I am not being asked to discontinue any other type of care that has been prescribed by my doctor(s), unless otherwise directed by the doctor(s) who prescribed them.

I also understand that any improvement in my health that results from my CBT treatment may result in a change in the dosage for my medication which other doctors have prescribed for me.

I agree that I will consult my medical provider to determine if my prescription needs to be changed.

Informed Consent Agreement (CBT)

I understand that I should not discontinue any health care provided by other health care providers, and that I should fully inform other health care providers about any changes in my symptoms or conditions that result from the application of CBT procedures.

I understand that I may discontinue my CBT treatment at any time. However, I understand that the premature termination of my care may be detrimental to any improvement I have obtained.

I understand that Dr. Smith is a chiropractic physician, and not a medical doctor or a doctor of osteopathy, and he does not practice medicine.

I understand that CBT techniques and procedures were developed by Dr. Smith, and that they are an experimental, alternative form of healthcare which is not yet proven by medical science, not yet subjected to chiropractic peer review nor taught in chiropractic colleges, and may not be covered by any health insurance, Medicare or Medicaid.

I have read the above statements, and I have been provided the opportunity to ask any questions regarding CBT procedures. I have also been informed that I am to notify Dr. Smith if I develop any problems during my treatment.

I understand the conditions stated above, and hereby consent to participate in this type of care. By signing below, I agree to the terms set forth above.

Private Membership Association

LymeStop is provided by Dynamic Health, a Private Membership Healthcare Association. A Private Membership Association (PMA) is any kind of business or group where services and participation are limited to members only -- and not open to the general public. A Private Membership Association establishes its own guidelines of operation that are agreed upon by all joining members. Because of the government-run healthcare system, this change is necessary to protect our freedom of choice. Specifically, it protects our right to continue to provide holistic alternative healthcare, and your right to receive our services without restriction. Unfortunately, many progressive clinics like ours have experienced an increasing amount of government interference. However, a Private Membership Association protects our freedom of choice and association as stated in the 1st and 14th Amendments of the U.S. Constitution. You will be asked to review and sign a Membership Agreement. Membership dues are a legal requirement to join a Private Membership Association. We have chosen a fee of only $10.00 for a lifetime membership to Dynamic Health. The Association does not bill insurance for services rendered. It also does not provide reports, treatment plans or diagnostic coding for the purposes of insurance reimbursement. Our Private Membership Association gives us the constitutional right to gather in private, and practice and receive the type of health care that we choose.

DYNAMIC HEALTH (A Private Membership Healthcare Association) MEMBERSHIP AGREEMENT

I, for membership fee paid in hand, do hereby apply for membership in Dynamic Health, a private membership organization. With the signing of this membership agreement I/we accept the offer made to become a member of Dynamic Health and have read and agree with the following Declaration of Purpose from Article I of Dynamic Health’s Articles of Association.

1. This Association of members hereby declare that our main objective is to maintain and improve the civil rights, constitutional guarantees, and political freedom of every member and citizen of the United States of America. We believe and affirm that the Constitution of the United States is one of the best documents ever devised by man, and the signers of the Declaration of Independence did so out of love for their country.

2. We believe that the First Amendment of the Constitution of the United States of America guarantees our members the rights of free speech, petition, assembly, right to contract, and the right to gather together for the lawful purpose of advising and helping one another in asserting our rights under the federal and state constitutions and statutes. We strive to maintain and improve the civil rights, constitutional guarantees, freedom of choice in health care, and political freedom of every member of this Association. IT IS HEREBY DECLARED that we are exercising our right of “freedom of association” as guaranteed by the First and Fourteenth Amendments of the U.S. Constitution and equivalent provisions of the various state constitutions. This means that our Association activities are restricted to the private domain only.

3. We declare the basic right of all of our members to select spokesmen from our number who could be expected to give wisest counsel and advice concerning the need for physical and mental health care assistance, and to select from our number those members who are the most skilled to assist and facilitate the actual performance and delivery of therapy, treatment and care.

4. We proclaim the freedom to choose and perform for ourselves the types of therapies and treatment modalities that we think best for diagnosing, treating and preventing illness and disease of our minds and bodies -- and for achieving and maintaining optimum wellness. We proclaim and reserve the right to include health care options that include, but are not limited to, cutting edge treatment modalities and therapies practiced by any type of health care practitioner -- whether traditional or nontraditional, conventional or unconventional.

5. Specifically, the mission of our Association is to provide members with what we feel are the most effective, natural alternative treatments available – at an affordable fee. We emphasize the evaluation and treatment of members’ overall health, and not merely their symptoms. The Association provides consultations, examinations, treatment, and advice for a wide variety of health-related problems. The Association’s examinations utilize muscle response testing, energetically-imprinted vials, magnets, and specific points on the body. The Association’s treatments are designed to correct health problems that are related to: pathological microorganisms (viruses, bacteria, fungus, parasites and protozoa); food and environmental allergies and/or sensitivities; environmental toxins; dysfunction of the organs, glands, soft tissues and joints; and nutritional deficiencies. The Association’s treatments utilize, but are not limited to: magnets, therapeutic touch, energetically-imprinted vials, specific manual therapy and nutritional therapy. The association also offers nutritional products and health-related information to its members.

6. The Association will recognize any person (irrespective of race, color, or religion) who is in agreement with these principles and policies as a member. The Association will provide a medium through which its individual members may associate for actuating and bringing to fruition the principles and purposes heretofore declared.

MEMORANDUM OF UNDERSTANDING

I understand that the fellow members of the Association who provide services and care, do so in the capacity of a fellow member and not in the capacity as a licensed health care provider.

I further understand no doctor-patient relationship exists within the association, but only a contract member-member Association relationship. In addition, I have freely chosen to change my legal status as a public patient, customer or client to a private member of the Association.

I further understand that it is entirely my own responsibility to consider the advice and recommendations offered to me by my fellow members. It is also my responsibility to educate myself as to the efficacy, risks, and desirability of same.

I understand that the acceptance of the offered or recommended diagnosis, therapy, treatment and care is my own carefully considered decision. Any request by me to a fellow member to assist me or provide me with the aforementioned diagnosis, therapy, treatment and care is my own free decision and it is also an exercise of my rights, and made by me for my benefit.

I agree to hold the Trustee(s), staff and other worker members and the Association harmless from any unintentional liability for the results of such care. This excludes any harm that results from instances of a clear and present danger of substantive evil as determined by the Association, as stated and defined by the United States Supreme Court.

The Trustee and members have chosen M. Anthony Smith as the person best qualified to perform services to members of the Association, and have entrusted him to select other members to assist him in carrying out that service.

In addition, I understand that the Association is protected by the First and Fourteenth Amendments to the U.S. Constitution. It is therefore outside the jurisdiction and authority of Federal and State Agencies and Authorities concerning any and all complaints or grievances against the Association, or any Association Trustee(s), members or other staff persons.

All rights of complaints or grievances will be settled by an Association Committee and will be waived by the member for the benefit of the Association and its members. Because the privacy and security of membership records maintained within the Association have been held to be inviolate by the U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process. Any medical or healthcare records kept by the association will be strictly protected and only released upon written request of the member.

I agree that violation of any waivers in this membership contract will result in a no contest legal proceeding against me. In addition, the Association does not participate in any medical insurance plans or collections on behalf of the member.

I agree to join the Association, a private membership association under common law, whose members seek to help each other achieve better health and have optimal quality of life.

I understand that any doctors, nurses, and other providers who are fellow members of the Association are offering me advice, services, and benefits that do not necessarily conform to conventional health care. I do not expect these benefits to include on-call coverage, hospital care, or the usual and customary care provided by most physicians. I will receive such primary and specialist care elsewhere.

I fully understand that the benefits I receive from the Association are not covered by any health insurance or Medicare.

As a member, I accept the goals of helping my body function better and choosing techniques that are both very safe and have a reasonably good chance to succeed, realizing that no diagnostic technique or treatment is foolproof. If I choose to forgo drugs, surgery, or radiation that has been recommended to me by others, I fully accept the risk that I might suffer serious consequences from that choice. Other aspects of informed consent will take place in my discussions with the providers and my fellow members of the Association.

My activities within the Association are a private matter. I refuse to share them with any State Licensing Board, the FDA, FTC, Medicare, Medicaid, or my own insurance company without my expressed specific permission. All records and documents remain as property of the Association, even if I receive a copy of them.

I fully agree not to file a malpractice lawsuit against a fellow member of the Association, unless that member has exposed me to "a clear and present danger of substantive evil". I acknowledge that the members of the Association do not carry malpractice insurance.

I enter into this agreement of my own free will or on behalf of my dependent without any pressure or promise of cure.

I affirm that I do not represent any State or Federal agency whose purpose is to regulate and approve products.

I have read and understood this document, and my questions have been answered fully to my satisfaction.

I understand that I can withdraw from this agreement and terminate my membership in this association at any time.

These pages and Article I of the articles of association of the Association consist of the entire agreement for my membership in the Association and they supersede any previous agreement.

I understand that the membership fee entitles me to receive those benefits declared by the Trustee(s) to be "general benefits" free of further charge.

I agree to pay for benefits that I receive that are declared by the Trustee to be "special assessments", per the Association's current fee schedule.

I hereby certify, attest and warrant that I have carefully read the above Contractual Application for Membership and I fully understand and agree with same.

Signature

I understand and agree to the above Procedures and Fees.
I agree

I hereby request that Dr. M. Anthony Smith evaluate and treat me (or my dependent) with CranioBiotic Technique (CBT), hereafter referred to as CBT.
I agree

I agree to the Private Membership Healthcare Association Membership Agreement
I agree

I have executed the foregoing on today's date.
I agree

Your Full Name, in lieu of signature. If Minor, signature of parent or guardian.