New Client Intake Form
1) I understand that I am advised by CornerStone Integrative Care LLC that it is necessary to communicate my intentions to participate in this program with my physician, describing its various components with my physician, and will obtain permission from said physician prior to receiving these services. If my physician is of the opinion that participation in this program offered by CornerStone Integrative Care LLC will aggravate any symptoms, illnesses or disorders which my child/self may have, or will it be harmful, injurious or detrimental to the health, safety or well-being of my child/self I will not participate in this program.
2) I warrant and represent that my child/self is (are) in good physical and mental health and have no ailment, disability or impairment which might prevent him/her/myself from receiving these services or which might be aggravated or activated by such services.
3) I am aware that each human body is different structurally and bio-chemically and will react differently to the services provided. Accordingly, there is no certainty or predictability as to how my, or my child's body, might react. I acknowledge that I am participating in this program of my own free will. CornerStone Integrative Care LLC has not made any claim, promise or guarantee regarding the effectiveness, usefulness, performance or safety of this program.
4) I understand that the services provided by CornerStone Integrative Care LLC are not a substitute or alternative to medical care. I retain the responsibility for ensuring that my child/self is under the regular and continuous supervision of a licensed physician.
5) I am aware that under no circumstance will the services provided by CornerStone Integrative Care LLC diagnose. treat, operate on or prescribe for any disease, pain, injury, or physical condition. Only a licensed physician may engage in such activities.
6) Costs for the services, therapy, supplements of the program have been disclosed to me. I understand that all prices are subject to change, I have been notified that any costs involved by CornerStone Integrative Care LLC will NOT BE COVERED by medical insurance and that no medical or insurance coding will be provided on any invoices.
7) CornerStone Integrative Care LLC will accept vitamin/supplement returns within 30 DAYS of purchase provided they are unopened and in good condition. However, IMPRINTED ITEMS CANNOT BE RETURNED.
8) I understand that payment is due within 30 days unless other arrangements have been made
9) 24 Hour cancellation notice miust be made in order to not be charged for the appointment. Exceptions can be made for emergencies only. A 50% cancellation fee will be applied for missed appointments.
10) I am aware that these services require that I provide confidential health information regarding my child/self to CornerStone Integrative Care LLC and any affliliated health care practitioners within the practice.
11) I acknowledge that I have evaluated the advisability of my child's/own participation in the program provided by CornerStone Integrative Care LLC. I, in turn, take full responsibility for the physical, mental and emotional transformations attained as a result of such participation. In consideration of CornerStone Integrative Care LLC's consent to allow my child/self to participate in the program, I hereby agree for myself, my heirs, and assigns to hold CornerStone Integrative Care LLC harmless for any and all liability arising out of my child's/own participation in the program or receipt of any services. I take full responsibility for any and all injuries or losses, and freely, knowlingly, and voluntarily agree to assume all risks involved, if any, during the program.
BY ACKNOWLEDGING AND SIGNING BELOW, I AM AGREEING TO THE ABOVE ELEVEN POINTS AND DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.