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Personal Health and Consent Form

Personal Health and Consent Form

CLICK HERE if you prefer to download a PDF of this form to print and fill out or you may fill out the form here.

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, please also inform your Natural Practitioner.

Personal Health and Consent Form

Name:

Phone:

DOB

Email:

Street Address

City

Zip

Occupation

In case of emergency contact

Phone

Do you frequently suffer from stress?

Yes

No

Do you have diabetes?

Yes

No

Do you experience frequent headaches?

Yes

No

Are you pregnant?

Yes

No

Do you suffer from arthritis?

Yes

No

Are you wearing contact lenses?

Yes

No

Are you wearing dentures?

Yes

No

Do you have high blood pressure?

Yes

Yes, I am taking high blood pressure medication

No

Do you suffer from epilepsy or seizures?

Yes

No

Do you suffer from joint swelling?

Yes

No

Do you have varicose veins?

Yes

No

Do you have any contagious diseases?

Yes

No

Do you have osteoporosis?

Yes

No

Do you have any allergies?

Yes

No

Do you bruise easily?

Yes

No

Any broken bones in the past two years?

Yes

No

Any injuries in the past two years?

Yes

No

Do you have cardiac or circulatory problems?

Yes

No

Do you suffer from back pain?

Yes

No

Do you have numbness or stabbing pains?

Yes

No

Are you sensitive to touch or pressure?

Yes

No

Do you have tension or soreness?

Yes

No

Have you ever had surgery? If you have, please explain.

Other medical condition, or are you taking any medications I should know about? If Yes, please explain.

Other Comments

I understand that it is my sole responsibility to be in charge of my own personal health and that I have answered the above questions honestly. I understand that I have sought out the services of a Minister and that the services to be provided are focused in Natural Healing and are of a Spiritual Nature. Having requested the services of an Officer of the Church, I understand that such services constitute for the New Haven Native American Church. Medicine Man or Woman, as a Person under the Law, as an Ecclesiastic Body in General, and as a Church Entire, the very establishment and practice of their Religion. I will make it my personal responsibility before any services shall be performed, to understand the kind and nature of the service to be provided and the level of competence of the person providing such service. I understand there are limits to the confidentiality that the Minister can provide. I understand this limits of confidentiality are due to breaches in electronic transmissions, subpoena or other dictates of Law, theft of records, and other such extenuating circumstances. Also any audio or visual recordings automatically brings the risk of violation of Confidentiality therefore if any service is to be recorded, I will be informed of the use of any such devices. I also agree to keep the Minister/Natural Practitioner updated to any changes in my medical profile. If I experience any pain, discomfort, emotional stress, or other unusual condition during any service, I will immediately inform the Minister. I have been adequately informed of all services, competence of the Minister, limits of confidentiality, and herby do give my consent for such services to be preformed.

I understand

I do not understand

By typing your name you acknowledge your consent.

Date

Consent to Treatment of Minor: By my signature below, I hereby authorize the Minister/Natural Practitioner to minister to my child or dependent as they deem necessary.

Date

Thank you for contacting us.

We will get back to you as soon as possible.

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Life Healing

Inner Peace Creates World Peace

World Peace through Inner Peace

Rebecca Debus, Life Healing
Skippack Township, PA 19438

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