Natural Health Consultant, Michelle Haley DHHP, RCST®, HTMA Practitioner Practitioner Diploma Heilkunst, Diploma Biodynamic Craniosacral Therapy, Hair Tissue Mineral Analysis Practitioner
I the client, give my consent to Michelle Haley to keep a file with my personal information, whether given orally, in writing or electronically. My signature below provides consent for Michelle Haley to gather in a secure confidential file, from now on, all information that I provide. Unless I instruct otherwise in writing, this consent will extend for seven years from the last information provided. I the client, understand that the use of hTMA as utilized by Michelle Haley, Natural Health Consultant, is not utilized nor intended for diagnostic purposes and is solely used to ascertain understanding of the individual’s mineral patterns within the context of that individual’s historic stress patterns and therefore his or her mineral system’s response to those stressors. I the client, am aware that a natural health consultant may not perform any medical act reserved for licensed professionals. These include (but are not limited to) diagnosing, prescribing and discontinuing pharmaceutical medication. For these services, I may see a medical doctor. I am not an employee of, nor associated with, any institution or government office that could gather any material or information, spoken or observed, for the purpose of entrapment or any action (legal, journalistic or otherwise) against Michelle Haley. I the client, am aware of this clinic’s cancellation policy and that if less than 24 hours notice is given for cancellation or rescheduling an appointment, the full session fee is due and payable to Michelle Haley. Please Initial Below (which means you've read and understand this clinic's cancellation policy):
Acknowledgement and Consent to Receive Services:I have read and understand the above disclosure. I understand that Michelle Haley is not a licensed physician and that the healing arts sought out by me with Michelle Haley are not licensed by the province. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have freely chosen to use the services offered by Michelle Haley, and agree to be personally responsible for the consultation fees of Michelle Haley in connection with the services provided to me, and that these services provided by Michelle Haley may not be covered by my health care insurance plans. Please initial Below (which means that you've read the above):
If you are a parent filling this out for your child who is below the age of 18, please enter your child's name below:
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