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  Meridian Sciences Foundation for Wellness and Treatment

Quantum Health Research Institute

3788 Oakdale Avenue, Pasadena, CA 91107

(626) 229-9818

www.qluni.org

Informed Consent & Information Release

Welcome to Quantum Health Research Institute!  We are a 501C-3 non-profit Corporation dedicated to Quantum Qi Research and human health.  Founded and Directed by Dr. Shui Yin Lo, Ph. D.  Dr. Lo has a research focus of trying to bridge the gap between East and Western disciplines thru conducting research and gathering scientific evidence for the effectiveness of Qi healing explaining the process in a quantum physics framework resulting in a unified view of Qi in its most fundamental aspects.

As a research institute affiliated with major universities, we are gathering data for validation and proof of the efficacy of Life Crystal Water based on stabilized water clusters to help improving your health. The results are for publication and for teaching.  Any health information we gather may be used in publication either in print or in digital format for video and internet use.

In studying and documenting changes in the body before and after application of Life Crystal Water, we utilize Infrared Imaging Scan (Thermography) to measure the thermal changes on the surface of the body, which are related to biochemical processes inside the body.  Undressing is required for the scan to be accurate.  The camera cannot read areas where IR emissions are blocked.  This is performed in privacy by the technician.  After the initial scan, you will redress and drink one cup of Meridian Crystal Water. A 20 minute session of rest in the room will be provided after drinking the water, and an immediate set of thermographs will be taken following the rest session to measure and document changes. The Thermograph scan is NOT an ordinary photograph but simply a thermal pattern on the surface of your body. It shows areas of imbalance. It is NOT intended to diagnose or treat any specific disease.  

Consent & Release of Information:  I voluntarily consent to the procedures and therapies outlined above and am under no duress.  I give permission for Dr. Lo and/or Quantum Health Research Institute to use my health information for research purposes which may include use in printed, video and audio formats.  I understand that my personal identity, health or financial information will not be sold or given to any marketing group for the purpose of commercial use and my anonymity will be preserved.

Signature: 

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Date: 

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Printed Name: 

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Phone Number: 

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Quantum Health Research Institute 

3788 Oakdale Avenue, Pasadena, CA 91107

(626) 229-9818

www.qluni.org

INITIAL CLIENT QUESTIONAIRE

Name: 

_____________________________________       

Date of Birth: 

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Address: 

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Home Phone: 

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Work/Cell: 

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Email: 

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Referred by:

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Emergency Contact: 

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Phone: 

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1.  Are you currently being treated for any conditions or illness? 

2.  Are you currently on any prescription medications and supplements?  Please list.

3.  Any surgeries, implants, pacemaker, etc.?  Please list type and year.

4.  List any past injuries and trauma, broken bones, accidents.

FOR THE FOLLOWING QUESTIONS, PLEASE ELABORATE ON ALL YES ANSWERS, THANK YOU.

5.  Any problem with brain function, memory, sleep, headaches, seizures?  [  ] Yes  [  ] No  

6.  Any problem with eyes, ears, nose, balance?  [  ] Yes  [  ] No  

7.  Any problem with lungs and breathing?  [  ] Yes  [  ] No 

8.  Any problem with heart and circulation?  [  ] Yes  [  ] No  

9.  Any problem with your digestion and elimination?  Bowel transit time?  [  ] Yes  [  ] No  

10.  Any problems with kidneys, bladder, urination?  [  ] Yes  [  ] No 

11.  Any glandular problems, i.e. thyroid, pancreas, adrenal, liver?  [  ] Yes  [  ] No 

12. Any problem with reproductive organs, i.e. uterine, ovarian, prostate or testicular, etc.  [  ] Yes  [  ] No   

13.  Any head, neck and spine issues?  [  ] Yes  [  ] No 

14.  Any dental, oral and throat issues?   [  ] Yes  [  ] No 

15.  What is your reason for coming to see Dr.  Lo? 

(Describe pain if any and rate on a scale of 1-10, 10 being most painful).

 deANGELO WILLIAMS age 3

Meridian Sciences, is a nanotechnology company focused on improving the immune functions in human body through a natural water catalyst called “Life Crystal” that naturally stimulates and actually “triggers” the body’s immune system. 

In a recent clinical trial, 9 patients blood were analyzed over a 45 day period while drinking the Life Crystal.  The results were startling with 8 out of 9 showing dramatic improvements in their immune system function.

The Company has commenced the largest human trial ever conducted by a homeopathic research institute in conjunction with a host of nonprofit organizations presently focused on research in Aids, Cancer, Alzheimer’s, Lupus and Parkinson’s diseases, among others.

We invite you to explore this newly discovered but ancient secret—a nano size cluster of H2O natural water clusters we believe may be the “transistor” of life appropriately called the “Life Crystal”.