I, First Name Last Name, voluntarily consent to the rendering of health care services and treatment utilizing holistic alternatives/CAM (complementary and alternative medicine) therapy as discussed with the staff of SynerGy Consulting, LLC for myself and/or the above stated patient. I understand that holistic treatment/CAM therapy is not a part of or approved by any medical guidelines. I also understand there are risks associated with the treatment of which I agree not to hold SynerGy Consulting, LLC, it’s providers, staff or any of its affiliates liable or pursue any legal action against them. I understand that there are associated side effects and possible drug interactions that are unknown and not fully understood at this time and I am taking full responsibility of the consequences associated with the treatment. I also understand that the treatment may not yield the desired outcomes. I also agree to communicate the side effects and any concerns with my provider. I agree to follow the directions as prescribed by my provider.By signing this consent and release of liability form, I acknowledge that I am agreeing to all of the statements above. I also acknowledge that I release SynerGy Consulting, LLC and it’s affiliates of all liability and agree not to pursue any legal action against them.