Wellness Evaluation and Release
Health Concepts
Wellness Evaluation and Release Form
Our goal at Health Concepts is to bring your body to balance structurally, nutritionally, and emotionally. This will allow your body to achieve optimum health and well being. Any lack of these areas may yield dis-ease in the body.
I understand that the attending consultant is a Doctor of Chiropractic and not a Medical Doctor, and that any testing procedures, therapies, or suggestions do not replace or intend to replace medical treatments or procedures. Our focus is health and wellness and promoting the body to heal itself.
We do not claim that any interventions “cure” any disease. We treat the patient and the body as a whole. We do not treat any type of “disease”.
One of the testing procedures that are available is Bio-Energetic testing. This testing provides an opportunity to measure electrical responses and meridian flows of the body. Bio-Energetic evaluation of the energy flows helps to identify various stresses that might impede the electrical process of the body. The evaluation may include recommendations for natural remedies or supplements, stress reduction methods, and/or nutritional changes designed to balance the energy meridians and enhance overall wellness. These recommendations are not cures for any known diseases, nor have they been proven clinically to eliminate any specific disease process.
The Bio-Energetic evaluation is not a method of diagnosing, nor are the suggested remedies designed to replace any the medications or treatments currently being provided or recommended by an allopathic physician.
I fully understand that the attending consultant is not an allopathic (medical doctor) and does not pretend to be, but is a Bio-Energetic practitioner and Chiropractor, providing services that are not allopathic, but that are within the parameters of natural health and wellness philosophy.
I fully understand that the attending consultant does not offer allopathic drugs, surgery, chemical stimulants, or radiation therapy, but is providing information and natural products to restore natural balance and optimum conditions for health and wellness based on the scope of his/her practice.
I fully understand that the attending consultant is not diagnosing or treating any illness or disease, but is only measuring the Bio-Energetic balance and overall stress response of the body, and that these services may not be generally accepted and/or recommended by an allopathic physician or other health professional.
I fully understand the attending consultant is in no way encouraging me to terminate or modify any previous or ongoing therapies under the direction of any licensed practitioner, and that the attending consultant can not/will not dissuade me from seeking allopathic attention, recommendations or modes of therapy from a licensed physician.
I presently seek consultation, advice, opinions, and/or programs, tests, evaluations, and/or products within the scope of the attending consultant’s wellness practice based upon the principles of holistic health and have solicited the attending consultant’s services in good faith, exerting my free will and following the dictates of my own conscience which allow me to select what I understand to be beneficial to my health.
If a minor or an incompetent person accompanies me, I give full faith that I am legally and totally responsible for them.
I authorize the attending consultant to provide his/her services to me on my behalf, and hereby release him/her from any and all claims and potential claims arising out of my actions or failure to act upon his/her advice.
I give full faith that I have read and understand this document entirely.
I hereby consent to and authorize the above-described consultation, evaluation, and health program.
Client Signature Date
Parent or guardian if under 18 years old
Witness Date