DISCLOSURE & CONSENT
You have the right to be informed about your health situation and the recommended healthcare steps to be taken so that you may make decisions after knowing the potential health benefits, risks and hazards, and alternatives involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent in a voluntary and intelligent manner.
By signing this form, I acknowledge and agree that I understand the following, with respect to services rendered by Jenny Sechler and such associates, technical assistants and other health care providers (“Provider”).
These services include: energy balancing, nutritional support, and dietary supplement recommendations for those people who no longer have a gallbladder because it has been surgically removed.
Provider has training in these services and is licensed in Provider’s home state (Texas) as a chiropractor and Nurse Practitioner and is also licensed as a Nurse Practitioner in Colorado but is operating in the capacity of a health coach in states in which Provider is not licensed, and, Provider is not necessarily relying on either of her licenses in offering these services within Texas or Colorado. Thus, the services contemplated hereunder may be considered alternative or complementary to healing arts services licensed by the State not as a substitution for healthcare through your designated primary care provider. These services are to provide support and for educational purposes to support living a healthy lifestyle without a gallbladder.
Benefits, Alternatives & Risks: Benefits of the above services include receiving health information and education that can augment my overall health and improve my healthcare decision-making, as well as overall lifestyle and nutritional support and overall balance. Alternatives include visiting licensed healthcare clinicians in person as appropriate. Risks include over-relying on health coaching and healthcare education; however, I am committed to monitoring my own health needs and seeing a physician, psychologist, or other licensed healthcare provider in an appropriate capacity when medically necessary. I understand that my overall health may be compromised if I am missing an organ or have been through major surgery, and that Provider cannot possibly address all risks to my health from these situations.
No Medical or Psychological Services: I am not engaging Provider for any medical or psychological services. I understand that Provider does not diagnose, treat, or claim to cure any medical or psychological condition, and that Provider’s services are not designed to replace conventional treatment methods of medical or psychological conditions. Provider does not handle medical emergencies of any kind. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a duly licensed practitioner (such as a licensed medical doctor or licensed psychologist) if I find that these distressing aspects create a danger for myself or for others.
Not Replacing Current Medical Care. Provider is not replacing care currently provided to me by other physicians or licensed healthcare providers, such as my current primary care physician, internist, gynecologist, cardiologist, gastroenterologist, pediatrician (in the case of children) or other specialty care. Provider has advised me that she does not admit patients to the hospital or treat hospitalized patients, and that I should maintain a relationship with a physician who is available to provide emergent and urgent care. If I encounter a medical emergency and am not able to obtain care from my primary care physician, I will contact 911 or report to a hospital emergency department.
No Claims or Guarantees: I understand that Provider makes no representations, claims or guarantees that my medical problems or conditions will be cured, solved, or helped by Provider’s recommendations.
Referrals: I understand that Provider may recommend that I seek other types of treatment from other health professionals who are not affiliated with Provider. I understand that Provider does not supervise these professionals and is not responsible for them. I understand that they are not her employees and that they will bill separately for their services.
Assumption of Risk; Indemnity: I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Provider from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the treatments or services described above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services. As a result, I agree not to pursue a claim against any of the foregoing, if I am dissatisfied with the results of the above services.
Telehealth: Telehealth involves the use of audio, video or other electronic communications to interact with you with respect to the services herein. Telehealth has benefits of speed of communication and access without physical travel; risks include inadequate communication due to the lack of physical presence. Additionally, in rare circumstances, security protocols could fail causing a breach of privacy. The alternative to telehealth consultation is a face-to-face visit.
Arbitration. Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in Los Angeles, California, before one (1) arbitrator. The arbitration shall be administered by AHLA Alternative Dispute Resolution Service Rules of Procedure for Arbitration, in Austin, Texas. Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. Each party has read and understood this Section (Arbitration) and understands that it thereby agrees to submit any claims arising out of this Agreement to binding arbitration, and that this dispute resolution provision constitutes a waiver of the Party’s right to a jury trial. HOWEVER, prior to either party initiating Arbitration of any dispute, the parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator in Los Angeles County. “Trained mediator” means a professional with actual training and experience in the field of Mediation and/or dispute resolution. EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION and UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, THE PARTY AGREES TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO MEDIATION AND ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.
NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I have carefully read this form and acknowledge that I understand it. I have had opportunities to ask questions, and accept and agree to all of the terms above. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.
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