Naturopathy Consent Form #2

I hereby attest to the following:

I understand that I am not consulting with Dr. Brenda Smith for medical, diagnostic, or treatment procedures. The services performed by her at her clinic are at all times restricted to helping me gain a better understanding of my level of bio-energetic health so that I will have a greater self-awareness and be better able to use a self-care program.

I understand that the use of the "Avatar" Elecrodermal Screening Equipment (EAV) and that recommendations, discussion, sale of nutritional supplements or homeopathics pertains to the "whole body" energetic concept of nutrition, and does not relate in the context of any specific ailment or condition.

I further understand that my appointments with Dr. Smith do not involve the diagnosing, prognosticating, treating, or prescribing of medicines for the treatment of disease, nor does any act performed by Dr. Smith constitute the practice of medicine, for which a license is required in the State of Oklahoma.

How To Fill Out the Form:
There are five steps below that tell you how to fill in the form by typing the needed info into the form from your computer before you print. If you do this, you won't have to write everything in. However, you can print the form first if you prefer (step 4 below), then write in (print) the needed info, ending with steps 2 and 5.

		Clickyour mouse in the first blank space and type in the required information. Tab for each additional entry. Be sure all blank spaces are filled in. Ifa minor is involved, please fill out the section below BEFORE you print. Printthe form (Right click with your mouse button, and select print). Signthe form and mail it to me with the saliva swabs you are going to send me (more info, see #2).
First Name:
Last Name:
Mailing Address:
City:
State:
Zip:
Phone Number with Area Code
E-Mail Address:
Date:
Reset Form:
Signed: ________________________________________________________ Please sign your name on the above line before mailing to Dr. Smith. Thank you.

Minor's First Name:		Clickyour mouse in the first blank space and type in the required information. Tab for each additional entry. Be sure all blank spaces are filled in. Completesteps 4-5 above. Be sure you sign in 2 places ... the line above, and the consent line below as parent/ guardian.
Minor's Last Name:
Parent or Guardian?
Date:
Reset Form:
I understand that by signing below, I am giving Dr. Brenda Smith my consent to evaluate the minor child above named.
Signed: ________________________________________________________ Please sign your name on the above line before mailing. This gives Dr. Smith your consent to evaluate your minor child. Thank you.