Authorizations and Consent Lifetime Authorization, Waiver and Release I, the undersigned, understand and acknowledge that Holistic Nutrition Services LLC is NOT treating me for any medical condition and that I am submitting myself for temporary consultations at my own risk, without the benefit of a physician’s examination, on this date and subsequent visits. I also understand the risks involved and the possibility of complications with recommendations and associated nutritional supplementation. In consideration of the foregoing and in consideration of consultations at my request, I do HEREBY RELEASE AND FOREVER DISCHARGE Holistic Nutrition Services LLC from any and all manner of actions and causes of actions, damages, malpractice or liability of any kind, nature, or character arising by reason of said consultations, whether heretofore or hereafter occurring, and whether or not now known by all parties thereto. It is the specific intent of this instrument to release and discharge any and all claims and causes of action of any nature whatsoever, whether known or unknown and whether specifically mentioned or not, which may exist or might be claimed to exist at any time prior to or after the date of this instrument. I, the undersigned, certify that no guarantees or assurances have been expressed, implied, or made as to the results that may be obtained from the aforementioned consultations or therapies. This therapy is educational and is not a substitute for medical care. If I am consulting with Holistic Nutrition Services LLC on behalf of a child or another person, I represent that (a) I am such child’s or other person’s legal guardian, (b) I understand that Holistic Nutrition Services LLC will provide advice based on information I convey and may not even meet the child or other person, (c) I have signed this Lifetime Authorization, Waiver and Release not only on my behalf but on theirs as well, and (d) I am considered the “client” of Holistic Nutrition Services LLC for all purposes and not the child or other person for whom I am legal guardian. I, the undersigned, do hereby certify that I have read and fully understand the contents of the above Lifetime Authorization, Waiver and Release. HIPAA Notice This notice describes how health information about you is used and disclosed in this office and how your privacy is protected. All health information, notes, test results, letters, emails, phone calls and any other method of communication between this office and you in regard to your health is kept private by this office. All information about you is stored in a secured location and is never given out to a third party unless there is a specific request by you to do so. We value your relationship and respect your right to privacy. I, the undersigned, have read the above notice and have had an opportunity to ask questions in regard to this notice. I understand that all confidential information collected by Holistic Nutrition Services LLC will not be shared without my prior authorization and that every effort will be made to protect my privacy. Payment Policies Please acknowledge the following policies by checking each one. 24 hour notice is required for appointment cancellations or re-scheduling requests. Holistic Nutrition Services, LLC reserves the right to charge for "no shows" or last minute cancellations. In case of illness or an emergency, please contact the office to re-schedule. Programs are available to you for a full year from the date of payment. There are no refunds for dropping out. Maintenance programs are available to you for the specified time period from the date of payment. There are no refunds for dropping out. I, the undersigned, do hereby certify that I have read, understand, and accept each of the above policies. Electronic Signature Authorization This website uses electronic signatures. If you agree to accept this policy, please check accept and sign below. I, the undersigned, accept the use of electronic signatures by Holistic Nutrition Services, LLC. Your Name (required) Your Email (required) Date I understand that by digitally signing my name above and clicking "Send" below, I am electronically signing this document. Click the Send button above Wait for a "Successfully Sent" message to appear below Click here to return to the Intake Forms Menu. Copyright (C) 2023 Holistic Nutrition Services, LLC. All Rights Reserved.
