Declaration and Consent to Treatment
Even the gentlest therapies have their complications in certain physiological conditions such as pregnancy and lactation, in very young children, or those with multiple medications. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease. It is very important that you inform your Holistic Energy Practitioner immediately of:
• Any disease process that you are suffering from
• If you are on any medication or over the counter drugs
• If you are pregnant, suspect you are pregnant, actively attempting to become pregnant or you are breast-feeding
I understand that my health care professional will answer any questions that I have to the best of her ability. I understand that the results are not guaranteed. I do not expect the Holistic Energy Practitioner to be able to anticipate and explain all risks and complications. I will rely on the Holistic Energy Practitioner to exercise judgement during the course of the procedure which they feel at that time is in my best interests, based on the facts then known. I understand that the Holistic Energy Practitioner works as an educator and advisor, therefore she only educate, consult, advise and assist her clients using one or more of the modalities being practiced. I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. If I am unable to make my appointment I must provide advance notification within 24 hours in which case no charge will be applied.
THIS IS TO ACKNOWLEDGE that I have been informed and I understand that:
• Any treatment or advice provided to me as a client is not mutually exclusive from any treatment, or advice that I may now be receiving or may in the future from another health care provider;
• I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice;
• This Holistic Energy Practitioner is NOT suggesting or advising me to refrain from seeking or following the directions of another health care provider;
• The treatment and therapies rendered or recommended by this Holistic Energy Practitioner may be different than those usually offered by a medical doctor or other health care provider;
• This Holistic Energy Practitioner does not treat or diagnose disease, and these therapies cannot be replaced with medical treatments.
I DECLARE that I have received a full and complete explanation of the treatment or services and that I have read and agree with its contents. I AGREE to pay my full account at the time of each visit or treatment, including fees for services, administrative fees as well as other applicable fees.