Please read the below consent information and fill out the below form to make us aware you have read and agree with these terms.

I understand that the practitioner does not diagnose illness, disease or any other physical or mental disorder. As such the practitioner prescribes neither medical treatment nor pharmaceuticals, nor performs spinal manipulations or psychological counseling. It is clear to me that Naturopathic, Holistic, Specialized Kinesiology and related energy work are not substitutions for medical examinations and/or diagnosis.

I understand that it is my responsibility to manage my health and wellness efforts. The practitioner does not prescribe or diagnose but may educate me as to natural food, supplement options, and protocols that may assist in improving my overall health and wellness.

I understand that as it is my responsibility for alerting the practitioner to any physical conditions or prescribed medications that would affect this work. I understand that my patient record will be held in strict confidence in accordance With HIPAA.

I understand that payment is due on the date of rendered service. I also understand that a minimum of 48 hours notice is expected if the need to cancel an appointment arises, otherwise I will be billed for the time that has been reserved for me and may have to prepay for future appointments at the time of scheduling.

I declare that the above information is correct to the best of my knowledge.