BioQuantum™ Practitioner Directory Intake Form

Thank you for your interest in being included in the BioQuantum™ Practitioner Directory. This directory is a curated, invitation-based listing created to support clarity, accessibility, and correct transmission of the BioQuantum work. Submission of this form does not guarantee inclusion. All practitioners must review and agree to the Practitioner Integrity Agreement prior to being listed.

Section 1: Practitioner Information

Name(Required)

First Last

Please enter your name exactly as you would like it displayed publicly.

Where is your practice located?(Required)

City Country

Section 2: Public Contact Information

Preferred Public Contact Method

Website

Booking Link

Enter Email Confirm Email

Website Or Web Booking Link (Calendly, Acuity, etc.)

Practitioner Specialty (Public)

Short Description of Your BioQuantum Practice

Guidelines:

2–3 sentences only
Focus on your area of focus or style of work
No medical claims, diagnoses, or guarantees
Avoid pricing or service lists

Examples:

GeneCode readings and integration sessions supporting conscious ascension and embodiment.
BioQuantum sessions focused on nervous system coherence, clarity, and energetic recalibration.
Conscious relationship and couple sessions through a BioQuantum lens.

Section 4: Insurance & Practice Confirmation (Private)

Professional Liability Insurance Confirmation

I currently maintain active professional liability insurance appropriate for my jurisdiction

I do not currently maintain professional liability insurance.

Selection of “I do not” may impact eligibility for listing.

Jurisdiction / Region of Practice

This information is collected for internal purposes only and will not be displayed publicly.

Practitioner Integrity Agreement Acknowledgment

Electronic Signature(Required)

First Last

I understand that submission of this form does not guarantee inclusion in the BioQuantum™ Practitioner Directory and that BioQuantum™ reserves the right to approve, update, or remove listings at its discretion. Please type your full legal name.

Date

Practitioner web badge

For approved practitioners who offer online session scheduling. All practitioners with an active website are required to display the BioQuantum™ practitioner affiliation logo. Please use the provided embed code to ensure the badge renders correctly and stays up to date."