Liver Flush Consent

Overview
The Liver Flush Program is a four-step process over thirteen days. People will respond differently to a liver flush based on several factors, including their toxin burden, liver health, previous liver flushes, dietary history, and past alcohol use. This program may be adapted based on personal experience. Individuals on a plant-based diet, for example, may not need to spend three days converting their diet. There are several components to the liver flush, including cleansing the digestive tract, softening gallstones, expelling toxins, relaxing the bile ducts, and clearing waste. Health benefits of a liver flush are not guaranteed and may vary for each patient.

Acknowledgement:*

I have read and understand the above Overview of the Liver Flush Program.

Disclosures
The purpose of the Liver Flush Program is to assist the body in ridding toxins from the body and improving the flow of bile. Liver flushes should not be used to mitigate overindulgence or to lose weight (although improved liver and digestive function may aid in weight loss). Liver flushes may not correct existing liver damage. Do not attempt a liver flush if there is a bowel obstruction, undiagnosed bowel disease, acute infection, pregnancy/nursing, chemotherapy, or stent in the biliary duct. Individuals who are frail or generally in poor health should not attempt a liver flush.

Acknowledgement:*

I have read and understand the above Disclosures of the Liver Flush Program.

Included Information
1. Instructions of the liver flush by steps.

2. Lists of supplies, supplements and basic groceries.

3. Directions on eating, supplements and adjunct therapies.

4. Schedules of each step of the liver flush

5. Suggested recipes for use during the liver flush.

Cost and Benefits
1. The Liver Flush Program information is $300.

2. Supplements, food and supplies are not included.

3. Patients will receive personalized support through portal messages and telemedicine visits as necessary, (visits outside the scope of the Liver Flush Program may incur additional charges disclosed to patients in advance).

Acknowledgement:*

I have read and understand the above Included Information, Cost and Benefits of the Liver Flush Program.

Acknowledgement:*

I understand that upon completion of this form, I will make a payment of $300 to Sparks Family Medicine using the "Online Payments" link on their website.

I wish to receive the Liver Flush Program material by (select one):*

Email (using the email below)ShareFile (using the email below)Online Access (password sent to the email below)

Email*

example@example.com

By signing below and their acknowledgements above, Patient acknoweldges that they have reviewed this document, understand its content and have had any questions regarding the Liver Flush Program answered by their provider.

Patient*

First NameMiddle Name/InitialLast Name

Date of Birth*

MonthDayYear

Signature*

Electronic Signature Acknowledgement and Consent*

I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.

Authorization to Receive Password Protected Attachment*

I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreement attachment. I must use the password Patient#1 to open the PDF.

Date*

MonthDayYear

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