Informed Consent for Whole Food Nutrition and Herbal Therapy
By signing this waiver I aknolwgde that, I will be provideded with whole food nutrition and herbal therapy services to support your health and well-being. The purpose of this informed consent is to ensure that you have a clear understanding of the nature of these therapies, potential risks, benefits, and alternatives, allowing you to make an informed decision about your participation.
Description of Therapy: Whole food nutrition and herbal therapy involve the use of natural foods and herbs to support your health goals. This may include dietary recommendations, supplementation with herbs, and guidance on lifestyle changes. I am not consuting for medical, diagnostic, or treatment procedures. These services are here to help you gain a greater self0awareness and be able to use a self-care program for daily living. No medicines are prescribes, anything prescribed does not relate in the context of any specific ailment or condition; Any nutritional adivse may have an effect on disease or symptms but is not intented to treat for any disease or symptom. Benefits: Whole food nutrition and herbal therapy aim to enhance your overall health and well-being. Potential benefits include improved nutrition, increased energy levels, better digestion, and support for specific health conditions. Risks and Limitations: While whole food nutrition and herbs are generally considered safe, there are potential risks. Allergies or adverse reactions to specific foods or herbs are possible. Additionally, the therapy might not be suitable for everyone and may not lead to the desired outcomes. Alternatives: You have the option to explore alternative approaches to address your health concerns. These alternatives may include medical treatments, other dietary approaches, or different therapies. Expected Results and Variability: Individual responses to whole food nutrition and herbal therapy can vary. While positive outcomes are possible, there is no guarantee of specific results. Confidentiality: Any information shared during your consultation and therapy will be kept confidential and used solely for the purpose of your treatment. Opportunity for Questions: You have the right to ask any questions you may have regarding the therapy, process, or any concerns you might have about the treatment. Voluntary Participation: Participation in whole food nutrition and herbal therapy is entirely voluntary. You can choose to decline or discontinue the therapy at any time without prejudice.
INFORMED CONSENT - YOGA THERAPY TREATMENT
By signing this waiver, I agree and understand the following: 1. The practice of yoga has certain hazards and risks and by which it requires physical exertion that may cause physical injury. 2. I have been advised to consult with a medical physician prior to joining a yoga class, workshop, or any session. 3. In case that instructors provide physical adjustments, I understand that I have the option to opt-out by letting my instructor know my wish not have physical adjustments. 4. I hereby release, waive, discharge and hold harmless the institution, its directors, officers, staff, volunteers, affiliates, and partners from any and all liabilities arising from any untoward incident in my participation to any class, workshop, and relevant sessions which may result to injury, loss, damage, or death. 5. In the event that any dispute arises out of this agreement, and in the event that the dispute could not be resolved amicably, I agree that the dispute shall be resolved by mediation before a mutually agreed and selected mediator by both parties. In the event that a mediation proceeding fails to resolve the dispute, the matter shall be resolved with an arbitrator. By signing this form, I hereby represent and warrant that I am physically fit and capable to participate for yoga classes, workshop, or activities. I agree and legally bind myself, with full understanding to the contents and meaning of the provisions above. I declare that I am over 18 years of age and fully capable in giving my consent. No refunds.
INFORMED CONSENT - EMOTIONAL CODE HEALING ART
The information contained in these materials is intended for personal use and not for the practice of any healing art, except where permitted by law. No representation contained in these materials is intended as medical advice and should not be used for diagnosis or medical treatment. I never attempt to diagnose the presence or absence of disease. The Body Code does not take the place of seeing a physician and is not designed to cure or treat disease. Consider reaching out to a professional trainer or gym of your liking. Always consult your health care provider before beginning any new exercise routine. Take any necessary precautions to avoid injury, staying in pain free ranges of motion. Take the recommended dose on the bottle, stop if any adverse reaction occurs. Dr. Rebecca is a licensed Chiropractor and Doctor of Chiropractic, however, videos produced are not intended to replace one-on-one therapy sessions. Everyone is unique and a broad yoga video will not relieve tensions for all. This is not intended to completely cure or to diagnose the causation of pain. You are responsible for moving slowly in pain free directions and to not push in painful areas. If a worsening of your pain occurs from any of these movements stop immediately and make an appointment with a local doctor. It is your responsability to move in pain free directions slowly. Voluntary Participation: Participation in Body Code is entirely voluntary. You can choose to decline or discontinue the therapy at any time without prejudice. No refunds.
INFORMED CONSENT - CHIROPRACTIC & BODYWORK TREATMENT
The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or dry hydrotherapy may also be used.
Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications.
Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered "rare".
Other treatment options which could be considered may include the following: Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases. Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases. Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.
Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.
Unusual risks: I have had the following unusual risks of my case explained to me. I hereby give my consent to the performance of diagnostic tests and procedures and chiropractic treatment or management of my condition(s). I understand that the treatment I receive at this clinic may be performed by advanced chiropractic interns under the supervision of a licensed Doctor of Chiropractic. I also understand that this is a teaching clinic and that student observers may be present during treatment. Chiropractic treatment or management of conditions almost always includes the chiropractic adjustment, a specific type of joint manipulation. Like most health care procedures, the chiropractic adjustment carries with it some risks. Unlike many such procedures, the serious risks associated with the chiropractic adjustment are extremely rare. Following are the known risks: Temporary soreness or increased symptoms or pain It is not uncommon for patients to experience temporary soreness or increased symptoms or pain after the first few treatments. Dizziness, nausea, flushing These symptoms are relatively rare. It is important to notify the chiropractor if you experience these symptoms during or after your care. Fractures When patients have underlying conditions that weaken bones, like osteoporosis, they may be susceptible to fracture. It is important to notify your chiropractor if you have been diagnosed with a bone weakening disease or condition. If your chiropractor detects any such condition while you are under care, you will be informed and your treatment plan will be modified to minimize risk of fracture. Disc herniation or prolapse Spinal disc conditions like bulges or herniations may worsen even with chiropractic care. It is important to notify your chiropractor if symptoms change or worsen. Stroke A certain extremely rare type of stroke has been associated with chiropractic care. Although there is an association between this type of stroke and chiropractic visits, there is also an association between this type of stroke and primary care medical visits. According to the most recent research, there is no evidence of excess risk of stroke associated with chiropractic care. The increased occurrence of this type of stroke associated with both chiropractic and medical visits is likely explained by patients with neck pain and headache consulting both doctors of chiropractic and primary care medical doctors before or during their stroke. Other risks associated with chiropractic treatment include rare burns from physiotherapy devices that produce heat. Bruising Instrument assisted soft tissue manipulation may result in temporary soreness or bruising. I understand that the practice of chiropractic, like the practice of all healing arts, is not an exact science, and I acknowledge that no guarantee can be given as to the results or outcome of my care.
I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and herby give my full consent to treatment.
No refunds.
HIPPA NOTICE OF PRIVACY PRACTICES
I acknowledge that I jave the right to receive and review the notice of pravacy practices for Karma Healing Chiropractic Inc. which describes practice policies and procedures regarding the use and disclosure of any of my protected health infomration created, recieved, or maintained by Karma Healing Chiropractic Inc.
PAYMENTSI am responsible for paying in full when I book the appointment. I will be provded a reciept if I ask for one.
CANCELLATION POLICY
To maintain excellence in customer service , I require a 48-
hour cancellation notification for my appointments. Please notify me within 48 hours to avoid a $50 charge for the missed appointment. I agree by this policy and I agree to pay 50 dollars to my credit card on file for failing to cancel within 48 hours. No refunds.