New Patient's Information

Full name:

Date of birth:

Occupation:

Address:

City:

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Referred by:

Please fill out to provide us with your current health information:

Exercise:

Other:

Medications:

I, the undersigned, hereby give voluntary consent for the administration of treatment by the methods of holistic medicine. 1. I understand that health and illness according to holistic medicine is different from that accepted by Western medicine. 2. I understand that there are no guarantees with Holistic medicine, and I volunteer to receive treatment. 3. I understand that the professional herbal supplements recommended and/or given to me as remedies are provided for my use in a manner delineated by the American Herbal Pharmacopoeia. http://www.herbal-ahp.org/ 4. I understand that I have not by any of the foregoing provisions agreed to cease or not pursue any conventional or non-conventional medical treatment and may continue with any other such treatment and/or seek any other professional medical opinions or treatments that I choose. 5. I understand that the treatments recommended at this office are not a substitute for treatments and health maintenance recommended by my physician. 6. I affirm that I have stated all my medical conditions and medications. I agree to indemnify, and hold harmless Holistic Health Services and Therapist(s) from and against any and all claims, demands, loss or liability of every nature, for injuries to person and/or property. 7. I agree to keep Holistic Health Services updated in the event that my medical condition changes. 8. In the use of ‘health or car insurance’ or ‘workers comp’ I understand it will be my responsibility to pay if they fail to take charge of the bill for the sessions I took. 9. If I fail to keep an appointment by neglecting to cancel my appointment within 24 hours, I will pay Holistic Health Services 100% of the fee for the missed appointment. I acknowledge that I am ultimately responsible for payment. Program cancellation because of travel plans need to be informed within 15 days. If I fail to inform the cancellation of my program and I do not cancel my sessions within 15 days of the trip taking place, I will pay Holistic Health Services 100% of the fee for the missed appointments within the 15 days period. I acknowledge that I am ultimately responsible for payment. I am of lawful age and have read and fully understand the contents of this document and the complete terms and conditions herein. This agreement contains the complete agreement between parties and no other guarantees or refunds will be given on products or services. Health Coach Package Choices are:

Check the box of the package you will be purchasing. Sessions are 2 hrs long:

single session at $180/ea (2 hrs long)
5 sessions at $160/ea (10 hrs package)
10 sessions at $150/ea (20 hrs package)

In an effort to advance the discipline of holistic health, improve our services and increase our knowledge, we occasionally video tape sessions. If you do not wish to participate, please check this box

I do not agree

I hereby certify by my agreement that I have read this entire form, that I understand all its provisions, that I have discussed any question to my satisfaction. I have answered all the questions honestly

I agree

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