PERMISSION & AUTHORIZATION FORM
REGARDING THE USE OF
CRAINO-SACRAL THERAPY / SOUND THERAPY / Nutritional Response Testing
PLEASE READ BEFORE SIGNING:
By signing below, I hereby voluntarily consent to Intuitive Health Restoration for the use of Cranio-Sacral Therapy, or Sound Therapy, and/or possible Nutritional Response Testing for the purposes of including assessments, examinations, and sessions, which may be recommended by Kelly Klann, RN, HHP, Cranio-sacral Therapist.
I acknowledge that Kelly Klann is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I understand that Cranio-sacral Therapist are not primary care providers. I clearly understand that Intuitive Health Restoration is not a substitute for a medical examination. I acknowledge that no assurance or guarantee has been provided to me as to the results of a therapy treatment session or series of sessions. I acknowledge that with any treatment there can be risks and those have been explained to me and I assume those risks.
I acknowledge and understand that the therapist must be fully aware of my existing medical and life conditions. I have disclosed to the therapist all those medical and life conditions affecting me. It is my responsibility to keep the therapist updated on my medical history and any life conditions that may affect my treatment. The information I have provided is true and complete to the best of my knowledge.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition from which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.