Application Form

Please fill the form

Adult Children Pets → Fee & Payment

Application Type

Section 1: Child and Guardian Information

Child’s Full Name

Child’s Date of Birth

Child’s Gender

Male

Female

Non-Binary

Other

Guardian’s Full Name

Guardian’s Relationship to Child

Guardian’s Contact Email

Guardian’s Phone Number

Current Address

Emergency Contact Name

Emergency Contact Phone

Relationship to Child

How did you know about the Quantum MedBed?

Your username on that platform

Section 2: Child’s Medical History

Primary Reason for Application

Current Medical Conditions

Current Medications/Supplements

Allergies or Sensitivities

Previous Surgeries or Treatments

Developmental and Lifestyle Factors

Diet Type

Balanced

Restricted

Other

Activity Level

High

Moderate

Low

Exposure to Toxins/EMFs

Section 3: Quantum Alignment and Consent

Intention Statement

As the parent/guardian, I consent to quantum scanning, frequency adjustments, and data sharing with Med Bed operators for my child. I understand this technology is experimental and results may vary.

Date

Section 4: Additional Notes

Application Fee

Expected MedBed Usage Day

Application Fee (USD)