New Patient Intake Form

ASSUMPTION OF RISK, WAIVER OF LIABILITY, INDEMNIFICATION AND HOLD HARMLESS ACCEPTANCE

 I ACKNOWLEDGE THAT:  

 

  1. I HAVE BEEN INFORMED OF THE NEED OF MEDICAL APPROVAL BEFORE JOINING IN THE INSIDE OUT PROSPERITY WELLNESS PROGRAM DESIGNED FOR ME, WHICH INCLUDES BUT NOT LIMITED TO: MIND, BODY, SPIRIT, NUTRITIONAL, SUPPLEMENTATION, AND FITNESS/TRAINING PROGRAM AND PROGRAM AND ANY OTHER RECOMMENDATION THAT WILL AID IN BRINGING IN MY WHOLE PERSON INTO BALANCE.

   2. I UNDERSTAND THAT A NATUROPATHIC DOCTOR IS NOT A LICENSED MEDICAL DOCTOR

   3. I AGREE THAT ANY INFORMATION, INSTRUCTIONS, OR ADVICE OBTAINED MAY NOT BE USED FOR A SUBSTITUTE FOR MY DOCTOR’S ADVICE

       OR TREATMENT

   4. I AGREE TO RELEASE AND DISCHARGE ANY AND ALL RESPONSIBILITIES OR LIABILITIES FROM INJURY ARISING FROM MY PARTICIPATION IN         ANY RECOMMENDED PROGRAM.

 

   5. I UNDERSTAND THAT RESULTS ARE INDIVIDUAL AND MAY VARY.

PLEASE CHECK THE ONE(S) THAT APPLY TO YOU

WAIVER OF LIABILITY:

 

PLEASE READ CAREFULLY

   1. I UNDERSTAND THAT A NATUROPATHIC DOCTOR IS NOT A LICENSED MEDICAL DOCTOR. 

   2. I UNDERSTAND THAT I SHOULD GET THE APPROVAL OF MY MEDICAL DOCTOR BEFORE THE START OF ANY/ALL NEW PROGRAMS.

 

   3. I AGREE THAT ANY INFORMATION, INSTRUCTIONS, OR ADVICE OBTAINED MAY NOT BE USED FOR A SUBSTITUTE FOR MY MEDICAL

       DOCTOR’S  ADVICE OR TREATMENT.

   4. I UNDERSTAND THE RESULTS ARE BASED ON THE PERSON’S HEALTH, HISTORY, AND ADHERENCE, THEREFORE,  RESULTS MAY VARY.

   5. I UNDERSTAND THAT BLOOD WORK MAY BE REQUIRED OR REQUESTED IN ORDER TO BETTER UNDERSTAND MY MACRO-NUTRIENT 

       UTILIZATION.

 

 RELATIONAL CURRENCY STANDARDS:

 

  1. ALL SCHEDULED APPOINTMENTS MUST BE CANCELLED OR RESCHEDULED AT LEAST 24 HOURS IN ADVANCE.  IF LESS THAN 24 HOURS, THE MISSED VISIT WILL COUNT AS 1 VISIT TOWARDS THE PAID PACKAGE. 

   2. IN ORDER TO SERVE YOU WITH EXCELLENCE, ADEQUATE COMMUNICATION IS APPRECIATED AND CELEBRATED. 

   3. THIRTY MINUTES LATE FOR AN APPOINTMENT WILL COUNT AS 1 VISIT. 

   4. CHILDCARE IS NOT PROVIDED. 

   5. IT IS THE DISCRETION OF THE PRACTITIONER TO REFUSE SERVICE FOR INAPPROPRIATE CONDUCT OR BEHAVIOR. 

   6. BECAUSE OF THE NATURE OF THE SERVICE, NO REFUNDS ARE PROVIDED.

   7. CREDITS FOR UNUSED SESSIONS WILL HAVE 30 DAYS FROM LAST SESSIONS TO BE UTILIZED.

Fax : (817) 549-2505

© 2020 Essence of Excellence

Essence of Excellence

601 Strada Circle, Ste 101

Mansfield, Texas 76063