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I authorize Longevity Health Center to disclose my protected past, present and future health information to the following persons or entities:

This health information may be used by the person I authorize for health treatment or billing/payment purposes. This authorization will remain in effect until such time as I choose to revoke the authority in writing.

I understand that the BSA test does not provide medical diagnosis and that my bio-energetic practitioner may recommend further medical testing. I give my permission for the bio-energetic practitioner to evaluate me. I understand that the practitioner will give me information about myself and make recommendations based on the bio-energetic screening. I understand that the practitioner will not make any recommendations on prescribed medications. My decision to follow through with the recommended program is my own decision and I hold the bio-energetic practitioner harmless. I understand that none of the practitioners, the associates or staff of Longevity Health Center are medical doctors. BSA testing will reveal "toxicity level disturbance signals". The modalities employed by Longevity Health Center practitioners are not approved for any type of medical evaluation. These "disturbance signals" cannot be corroborated by standard laboratory testing. This evaluation should in no way be construed as a medical diagnosis. I choose to undergo an evaluation and possible treatment in accordance with oriental medicinal principles, utilizing bio-energetic techniques. I have read and understand this STATEMENT OF UNDERSTANDING.