Authorizations and Consent

Authorization and Consent
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    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.
    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.
    Payment Policies
    Please acknowledge the following policies by checking each one.
    Electronic Signature Authorization
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