Consent Form

Consent for QBT Support (Please Tick)

I give consent for Annie Seeley to contact me regarding my nutrition support including sending relevant resources:

Use of Personal Data

Your data will be held Annie Seeley in-line with General Data Protection Regulations as set out in the policies and statements available at gaianutrition.org . To change your preferences at any point email gaianutrition@protonmail.com

Payment

Payment of the £200 for 1 voice screening, frequency balance files and any recommendations be paid on receipt of an invoice and the amount can be transferred via BACs  (already in receipt of payment).

Governing Law and Jurisdiction

The Agreement, and the relationship between You and myself, Annie Seeley (whether contractual or otherwise) shall be governed by and construed in accordance with the law of England & Wales.

Confirmation

I agree to the above terms and conditions and confirm that, to the best of my knowledge, the information given in Client Intake form is accurate and complete.

Informed consent

Please read the following information carefully and ask your practitioner if you have any questions:

While a traditional/holistic approach to care is typically considered to be safe, you should be aware that minor side effects can occur with Bioresonance therapy a headache may occur during or after listening to your balance files. If this occurs let your practitioner know. Other minor side effects might include nausea, flushing, tiredness. Please have open communication with your practitioner about any side effects or concerns.

Temporary aggravation of symptoms – with many types of healing, symptoms may sometimes worsen before improving, please advise your practitioner if symptoms worsen for more than a few days.

Supplements and herbs that have been recommended are considered safe and should be taken as directed. Some interventions may be inappropriate during pregnancy, or while taking other medications. It is important to inform your practitioner of all these situations and conditions. Possible side effects to these therapies include such things as gastrointestinal upset, skin rashes or mild worsening of symptoms. It is important to cease use immediately and inform your practitioner, in the case of adverse reaction.

STATEMENT OF CONSENT TO TREATMENT

As a client of Annie Seeley and Gaia Nutrition, I have read the information and I fully understand that this form of health care is based on holistic wellness principles and practices. As Gaia Nutrition is a holistic health practice; I recognise that all the practitioners that are working with me may have access to my file and will ensure all information is private and confidential. I also recognise that even the gentlest therapies potentially have their complications, and hence the information provided must be complete and inclusive of all health concerns including pregnancy, significant medical history and all medications (including over the counter drugs and supplements).

Annie Seeley (Registered Nutritionist BSc (Hons) RNutr utilises evidence-based nutrition information alongside holistic complimentary therapies. However, I do not expect Annie Seeley to be able to anticipate all fo the risks and complications associated with the interventions I choose. I have been informed of potential side effect reactions above. I understand that I am my most important health advocate. I will ask questions and maintain open communication with my practitioner about any concerns. I fully understand that there are possible side effects and will cease use and inform my practitioner about any concerns. I fully understand that there are possible side effects and will cease use and inform my practitioner immediately if these occur. I will also inform my practitioner immediately if I am pregnant. I understand that it is my responsibility to fully disclose all medications and supplements I may be taking, as this can influence the plan of care my practitioner and I develop. I agree to adhere to the plan of care and not make alterations on my own.

I hereby request and consent to developing and adhering to a plan of care utilising nutrition and holistic complementary therapies. I also confirm that I have the ability to accept or reject this care and treatment of my own free will and choice, and that I am not an agent of any private, local, associations or government agency attempting to gather information without so stating. I accept full responsibility for fees incurred during this care and treatment and understand that there are no refunds for services and a required 24 hour notice for all cancelled appointments, except for any emergency situations.