Terms of Acceptance
I specifically authorize practitioners of Custom Wellness to perform a health analysis and to develop a natural health improvement program for me to improve my health, and NOT for the diagnosis, treatment or “cure” of any disease.
I understand that “muscle-testing” or “energy-testing” is a safe, non-invasive, natural method of analyzing the body’s bio-energetic reflexes, and that imbalances in these areas could cause or contribute to various health problems. This work is not and cannot be used to render a physical diagnosis, nor is this work linked to any type of diagnosis.
I understand that the nutritional supplements or herbs received at this office or recommended from this office are not drugs or medicines. I understand that practitioners of Custom Wellness do not state recommendations or opinions about prescription drugs.
As with all health care treatment, no promises or guarantees can be made regarding the results of any analysis or nutritional program recommended.
I understand that the suggested nutritional program and dietary information is not intended as primary therapy of any disease or symptom. My intention is to find a good nutritional program that will assist me in changing my habits and establishing a new lifestyle in order to build good health naturally. I understand that this dietary health program is an adjunctive schedule of nutrients solely provided to upgrade and/or change to the quality of whole foods or herbals in my diet in order to supply good nutrition for supporting the physiological and biochemical processes of the human body.
I understand that the practitioners of Custom Wellness are not medical doctors and do not treat or diagnose medical conditions; that this is not a replacement for medical counseling; that if I have a medical condition, I will seek a qualified medical professional.
In addition, I understand that Custom Wellness requests a minimum of 24-hour advance notice for any cancellation or rescheduling of an appointment, and that insufficient notice or no notice will result in a late cancellation charge of $30.
I understand that “muscle-testing” or “energy-testing” is a safe, non-invasive, natural method of analyzing the body’s bio-energetic reflexes, and that imbalances in these areas could cause or contribute to various health problems. This work is not and cannot be used to render a physical diagnosis, nor is this work linked to any type of diagnosis.
I understand that the nutritional supplements or herbs received at this office or recommended from this office are not drugs or medicines. I understand that practitioners of Custom Wellness do not state recommendations or opinions about prescription drugs.
As with all health care treatment, no promises or guarantees can be made regarding the results of any analysis or nutritional program recommended.
I understand that the suggested nutritional program and dietary information is not intended as primary therapy of any disease or symptom. My intention is to find a good nutritional program that will assist me in changing my habits and establishing a new lifestyle in order to build good health naturally. I understand that this dietary health program is an adjunctive schedule of nutrients solely provided to upgrade and/or change to the quality of whole foods or herbals in my diet in order to supply good nutrition for supporting the physiological and biochemical processes of the human body.
I understand that the practitioners of Custom Wellness are not medical doctors and do not treat or diagnose medical conditions; that this is not a replacement for medical counseling; that if I have a medical condition, I will seek a qualified medical professional.
In addition, I understand that Custom Wellness requests a minimum of 24-hour advance notice for any cancellation or rescheduling of an appointment, and that insufficient notice or no notice will result in a late cancellation charge of $30.
|
After filling out this form, please fill out the Consent for Purpose of Treatment form, your final intake form.
|