• Holistic Questionnaire

    All Questions Must Be Answered
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  • Phone

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Format: (000) 000-0000.

  • WHAT ARE YOU EXPECTING TO RECEIVE FROM THIS APPOINTMENT?
    Is there anything specific you would like to work on during the session?
    WHAT ARE YOUR LONG-RANGE GOALS?

  • I UNDERSTAND THAT 24-HOUR NOTICE IS REQUIRED FOR ALL CANCELLATIONS. I WILL PAY IN FULL FOR ANY LATE CANCELLED APPOINTMENTS.

    MY SIGNATURE IS AUTHORIZATION TO CHARGE MY CREDIT CARD ON FILE FOR THESE CHARGES.

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  • COLON HYDROTHERAPY DISCLOSURE

  • I have been informed and agree to self-insertion and self-retraction of the speculum. Please initial      

  • Rows

  • If you are a Federal, State or Local agent, upon entering these premises you must declare same or under the Bivens Act, Article 42, be held personally and individually liable.

  • I have read the above and declare that I am not an agent.   
    Please initial:      

    Supplements: I take full responsibility for any products I choose to try, to assist my health during or after any sessions.   
    Please initial:      

    24 Hour Cancellation Policy: If you must cancel your appointment, please call 24 hours in advance or you will be charged in full for the appointment. If there is no answer when you call, you can leave a message, and we will acknowledge that you have cancelled your appointment so that we may reschedule.   
    Please initial:      

  • Please read all above carefully before signing:

    I have honestly answered all above questions and am not intentionally withholding information about my health. I am agreeing to the office policies and procedures.

    The purpose of this Center is to provide services and offer supplements to clients. The therapists and employees of this center provide the clients with services and information for the purpose of vocational and advocational self-improvement. All procedures are directed towards the establishment of this goal.

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  • HIPPA COMPLIANCE PATIENT CONSENT FORM

  • Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

    The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

    The terms of the notice may change, if so, you will be notified on your next visit to update your signature/date.

    You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1966) law allows for the use of information for treatment, payment, or healthcare operations.

    By signing this form, I understand that:

    • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
    • The practice reserves the right to change the privacy policy as allowed by law.
    • The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
    • The patient has the right to revoke this consent in writing at any time, and all full disclosures will then cease.
    • The practice may condition receipt of treatment upon execution of this consent.
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  • Informed Consent for Treatment

    Omaha Health Therapy Center, LLC

  • This document is a binding agreement (The Agreement) between Omaha Health Therapy Center, LLC [Sarah Kracht APRN and employees/representatives] and the Individual patient whose name and signature appears below (“You”/“Your”). In consideration of the health care service which you may be provided by Omaha Health Therapy Center, LLC [OHTC] at the present and always in the future. You agree as follows: Your agreement indicated by placing your initials on the lines following each section and by signing in the space provided:

    1. Consent for Treatment. You understand that the practice of medicine is not an exact science and that the diagnosis and treatment may involve risk of injury or death. You hereby consent to and authorize OHTC to provide you with health care treatments which, depending on your health conditions may include one or more of the following procedures: Naturopathic Medicine, Herbal Medicine, Intravenous Infusions, Intramuscular Injections, Intra-Articular and Extra-Articular Injection Therapy, Platelet Rich Plasma Injections, Prolozone Injections, Chelation Therapy, Nutritional Therapy; together these “treatments administered by any employee at Omaha Health Therapy Center, LLC. You acknowledge that no one at OHTC has made any guarantees or promises to the outcome or the safety and efficacy of the above listed treatments or any additional treatments not mentioned above.
    (Initials)      

    2. Experimental Nature of Treatments. You also acknowledge and agree that the treatments may consist in whole or part experimental procedures and methods, in which no government (including the US Food and Drug Administration), scientific or medical authority has confirmed the safety or efficacy thereof. You acknowledge that the safety and efficacy record of some of the Treatments are based only on empirical and anecdotal evidence, which only shows that the treatments appear to be relatively safe and effective. OHTC has informed you that the treatments may alter, address, or decrease your pain, symptoms, or complaints, but also may have no effect.
    (Initials)     

    3. Intravenous Therapy, Prolozone TM Injection Therapy Risks, Side Effects, Complications. OHTC hereby informs you that there are certain unavoidable risks and potential side effects and complications to the treatments, including without limitations: Swelling, severe pain, bleeding, dizziness, bruising, phlebitis, vomiting, fainting, metabolic disturbances. Treatments rarely cause infection, injury to nerves, or frozen shoulders.
    (Initials)     

    4. Description of Treatments. The exact procedure, as well as the recommended sequence of treatments will be explained to you when they are administered. You acknowledge that any of the treatments may involve inserting needles into your skin and/or veins and the injection of a chelating agent, and FDA approved prescription medicines, local anesthetic, concentrated sugar water (Dextrose), concentrates of your own blood, and on occasion, other substances will be explained to you before injection.
    (Initials)     

    5. Information You Proved to Omaha Health Therapy Center. You have provided OHTC with a complete list of all prescription and non-prescription medications (i.e. Dietary supplements, herbal medications) you are currently taking. It is your responsibility to update OHTC with all changes made to medications. You have also provided a complete list of all known allergies you may have and all allergic or adverse reactions you have had in the past to any medications, dietary supplements or medical treatments of any kind. You agree to update OHTC immediately should this list change.
    (Initials)     

    6. Assumption of risk. You hereby acknowledge that after having read carefully, you understand fully the terms of this agreement, have adequate time to ask any questions about this agreement and are willing to assume any and all risks associated with the treatments including without limitation those described in the agreement. You acknowledge that no explanation or description of any of the treatments can ever fully explain every possible risk, side effect, or complication that may or could arise from treatments. By initialing and signing this agreement, you acknowledge your willingness to assume such risks and that your consent to the treatments is willing, voluntary, and informed.
    (Initials)     

    7. Alternatives. You have been informed that there are alternatives to our treatments including other types of injections, prescription medications, surgery, and taking no action, to name a few.
    (Initials)     


    8. Miscellaneous. You agree that this agreement constitutes the entire agreement between you and Omaha Health Therapy Center, LLC regarding the subject matter hereof. No promise, representation, guarantee, or warranty not included in this agreement has been or is being relied upon by you. You do not hold OHTC responsible for any complications that may arise from your treatment at OHTC. This agreement shall be binding on you and your successors, heirs, legal representatives, and assignees. In case the provision of this agreement is held invalid or illegal, such provisions shall be curtailed, limited, or severed only to remove such illegality or invalidity. This agreement shall be governed by the laws of the State of Nebraska without regard to any choice of law principle.
    (Initials)     


    By signing this agreement, you indicate that You have read, understand, and agree to the terms; You have received a copy of this Agreement and that you are the patient, Guarantor, the Patient’s legal representative or legally authorized to sign this Agreement and accept its terms.

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  • Cancellation Policy

  • We understand that there are times when things come up. However, failing to call and reschedule, or cancel your appointment denies other patients the ability to book their own appointment and causes staffing issues.

    If you do not show up for your appointment you will be charged the full visit fee before being able to schedule your next appointment. If you call the day of, you will be charged 50% of the appointment. We expect the common courtesy of a 24 hour notice if you need to cancel your appointment. We appreciate your understanding.

    By signing this form you acknowledge that you have read and understood the cancellation and no show policy. 

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