ATP Reset Services Disclosure

ATP Reset/ATP Trauma Reset Disclosure

Sparks Family Medicine, Ltd.
Date*

MonthDayYear
Date
Client Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Responsible Party (if not the Client)

First NameMiddle NameLast Name
If Responsible Party, Relationship to Client
Email
example@example.com
This notice clarifies that the ATP Reset/ATP Trauma Reset services (“ATP Services”) provided by Dr. Sparks at Sparks Family Medicine, Ltd (“SFM”) to clients who are not patients of SFM. Client or client's representative understands and agrees as follows:
- ATP Services are energy work and not conventional medicine.
- ATP Services do not generate a medical record.
- ATP Services do not establish a patient/provider relationship.
- Payment for ATP Services is set by Dr. Sparks and due prior ATP Services appointment.
By signing below, client or client's representative acknowledges that they have reviewed this notice, they understand the content of this notice, and they agree to the content of the notice.
Name of Person Signing this Form*

First NameMiddle NameLast Name
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.
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 Client#1 to open and save this attachment.
Signature*

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ATP Reset/ATP Trauma Reset Disclosure