Quit Smoking Disclaimer
 
 
 
 
Vitality Clinic

 21/7 The Esplanade, Mt Pleasant  95 Woodbridge Dr. Rockingham

Phone: 0433 167 704

 

Terms of Acceptance, DISCLAIMER and LIABILITY WAIVER

When a patient seeks help to quit cigarettes and we accept a patient for such care, it is essential for both to be working towards the same objective.  Quitting cigarettes has specific goals.  It is important that each patient understand both the objective and the method that will be used to attain it.  This will prevent any confusion or disappointment.

           

We do not offer to diagnose or treat any disease.  We offer methods of restoring balance to your mind as a way of helping you quit cigarettes.  If you desire advice, diagnosis or treatment for anything going on in your body, we will recommend you seek the services of another health care provider.

 Advanced Hypnosis:

I understand that the hypnotherapist cannot guarantee results any more than a doctor can guarantee results from a particular prescription or surgical procedure.

I understand that hypnosis is not mind control, and that the hypnotherapist does NOT do anything to me while in or out of trance.

I understand no one on this planet has ever suffered adverse affects simply from being hypnotized.

NLP: Neuro Linguistic Programming

NLP is a system of working with the mind and the programming and ways in which the mind works. By working with the patterns, belief systems, and ideas the brain uses to store and retrieve information and ways the brain uses to carry out the functions of the body, NLP is often able to quickly help you change this “programming”. This allows you to make changes at the unconscious level in a matter of minutes, vs. days or years with other systems. NLP only works because you choose to do it or not. NLP cannot do anything you don’t want to be done.

Support Structures:

The quit cigarettes in 60 minutes system has follow up systems that you will do after the initial 60 minute session. You will be given all of these support structures at no additional charge at the end of your session. It is my understanding that the full benefit of this session will not be had unless I follow through with using and implementing the support structures given in this session.

Follow Up Sessions:

I understand that the quit cigarettes in 60 minutes system has NO STATED REFUND POLICY. The lifetime guarantee is for follow up sessions at no charge to help make you a non-smoker, for whatever it takes. That is your goal and we are going to support you in that 100%.

I understand THIS SESSION WILL BE RECORDED for Vitality Clinic’s client files

Again, we do not diagnose or treat.  We do not want to replace your medical doctor or alternative medical treatments. 

I, __________________________________, have read and fully understand the above statements.

(Print name)

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.  I will not hold this clinic, [your name here], or any of his staff liable for any adverse effect on my health; nor will I hold this clinic, [your name here], or his staff liable if I choose to go against my doctor’s medical advice.

I therefore accept the aforementioned types of care on this basis.  ________________________________     _________________

        (Signature)                                                               (Date)

Consent to evaluate and adjust a minor child: I, _______________________ being the parent or legal guardian of _______________ have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive the above care. 
 
 
 
 
 
 
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Lose Weight Disclaimer
 
 
 
 
Vitality Clinic

 21/7 The Esplanade, Mt Pleasant  95 Woodbridge Dr. Rockingham

Phone: 0433 167 704

 

Terms of Acceptance, DISCLAIMER and LIABILITY WAIVER

When a patient seeks help for lose weight and we accept a patient for such care, it is essential for both to be working towards the same objective.  Hypnotherapy has specific goals.  It is important that each patient understand both the objective and the method that will be used to attain it.  This will prevent any confusion or disappointment.

           

We do not offer to diagnose or treat any disease.  We offer methods of restoring balance to your mind as a way of helping you.  If you desire advice, diagnosis or treatment for anything going on in your body, we will recommend you seek the services of another health care provider.

Advanced Hypnosis:

I understand that the hypnotherapist cannot guarantee results any more than a doctor can guarantee results from a particular prescription or surgical procedure.

I understand that hypnosis is not mind control, and that the hypnotherapist does NOT do anything to me while in or out of trance.

I understand no one on this planet has ever suffered adverse affects simply from being hypnotized.

NLP: Neuro Linguistic Programming

NLP is a system of working with the mind and the programming and ways in which the mind works. By working with the patterns, belief systems, and ideas the brain uses to store and retrieve information and ways the brain uses to carry out the functions of the body, NLP is often able to quickly help you change this “programming”. This allows you to make changes at the unconscious level in a matter of minutes, vs. days or years with other systems. NLP only works because you choose to do it or not. NLP cannot do anything you don’t want to be done.

  

I understand that Vitality Clinic has NO STATED REFUND POLICY.  

I understand THIS SESSION WILL BE RECORDED for Vitality Clinic’s client files

Again, we do not diagnose or treat.  We do not want to replace your medical doctor or alternative medical treatments. 

I, __________________________________, have read and fully understand the above statements.

(Print name)

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.  I will not hold this clinic, [Vitality Clinic], or any of his staff liable for any adverse effect on my health; nor will I hold this clinic, [Vitality Clinic], or his staff liable if I choose to go against my doctor’s medical advice.

I therefore accept the aforementioned types of care on this basis.  ________________________________     _________________

        (Signature)                                                                (Date)

Consent to evaluate and adjust a minor child: I, _______________________ being the parent or legal guardian of _______________ have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive the above care.