General confidentiality and privacy agreement
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1. GENERAL PRIVACY AND CONFIDENTIALITY AGREEMENT FORM

This is a general privacy and confidentiality agreement form.

I would like to thank you for taking the time and effort in filling this out. For more information you may wish to visit the website at www.empowermenthealing.com

Light and love,

Adam

1.
I _, declare that

1. The service I receive from Empowerment Healing is to remain confidential and private.

2. The staff of Empowerment Healing are not medical practitioners and therefore cannot perform any services conducted by a medical practitioner.

3. Any information or advice given by a staff of empowerment healing is to be used at my own discretion and not as a substitute for medical advice or medication.

4. I acknowledge that I do not currently have any major psychological problems and that I am not under the influence of alcohol or illegal drugs.

5. I give the staff of empowerment healing permission to physical place their hands on parts of my body (in a non-sexual way), or to use specified equipment, which is deemed appropriate for the session. Such as hands on stomach or crystals on chakra points
Yes □
No □

6. I am happy to provide any information in which the staff of Empowerment Healing deem necessary in order to provide the services and products I requested, including medical background, current ailments and medication taken.

7. The staff of Empowerment Healing have the right to cancel or discontinue any services or products at any time if they feel it is necessary to do so.
I hereby agree to the terms stated above.

(Name of client)
(Signature)
(date)
____

(Name of staff)
(Signature)
(date)

I _____________________________, declare that 1. The service I receive from Empowerment Healing is to remain confidential and private. 2. The staff of Empowerment Healing are not medical practitioners and therefore cannot perform any services conducted by a medical practitioner. 3. Any information or advice given by a staff of empowerment healing is to be used at my own discretion and not as a substitute for medical advice or medication. 4. I acknowledge that I do not currently have any major psychological problems and that I am not under the influence of alcohol or illegal drugs. 5. I give the staff of empowerment healing permission to physical place their hands on parts of my body (in a non-sexual way), or to use specified equipment, which is deemed appropriate for the session. Such as hands on stomach or crystals on chakra points Yes □ No □ 6. I am happy to provide any information in which the staff of Empowerment Healing deem necessary in order to provide the services and products I requested, including medical background, current ailments and medication taken. 7. The staff of Empowerment Healing have the right to cancel or discontinue any services or products at any time if they feel it is necessary to do so. I hereby agree to the terms stated above. ______________________________ (Name of client) (Signature) (date) ______________________________ (Name of staff) (Signature) (date)

General confidentiality and privacy agreementExit this survey >>

1. GENERAL PRIVACY AND CONFIDENTIALITY AGREEMENT FORM

General confidentiality and privacy agreement
Exit this survey >>