International / Out-of-Country Client Agreement

Full Legal Name

First NameMiddle NameLast Name

Country of Residence

Email

example@example.com

Confirmation: I am physically outside Canada during the consultation

I am receiving services while physically located outside Canada;
the practitioner is physically located in British Columbia, Canada;
I have voluntarily requested the services;
I understand the limitations of remote consultation;
I understand that laws governing these services may differ in my jurisdiction;
I am responsible for determining whether receiving these services is permitted in my jurisdiction; and
I have read, understood, and voluntarily agree to the terms of this International / Out-of-Country Client Agreement.

Is the client a minor?

Parent/Legal Guardian Full Name

First NameLast Name

Client Signature

Date

International / Out-of-Country Client Agreement

Client Information

Agreement Acknowledgements

Signature and Date