Health Waiver & Consent For Treatment
I, understand that La Luna SoL offers holistic therapies and non-traditional
complementary interventions such as Reiki, Sound Healing,Energy work and other holistic modalities ,all of which
are intended to promote health and wellness, enhance relaxation, reduce pain, become relaxed and
more comfortable with your own thoughts, letting go of tensions and apprehensions caused by stress,
emotional barriers and physical /mental illnesses and offer a positive experience utilizing the concept
of mind, body, and soul in treatment intervention.
I understand that my practitioner is trained Reiki Practitioner, Holistic Wellness Coach and is not a
massage therapist, chiropractic doctor, registered nurse, registered dietitian, nor a medical doctor.
I understand, the practitioner is not qualified to diagnose, treat, cure, prevent or assess any disease,
disorder or condition. I understand, the practitioner is not qualified to prescribe medication or dietary
alternatives.
I understand that holistic therapy interventions are not a substitute for medical treatment or
medications, and that it is recommended that I concurrently work with my primary healthcare provider
for any condition I may have. I am aware that the practitioner does not diagnose illness or disease,
does not prescribe medications, and that spinal manipulations are not part of holistic therapy.
I wholeheartedly understand that following any set regime does not promise any form or level of cure
for any specific (or otherwise) condition. I promise to abide by any warnings or contra-indications
given to me through consultation if products and services are used.
I understand that I am under no obligation to follow any recommendations for treatment given.
I have informed the practitioner of all my known physical and medical conditions, and I will keep the
practitioner updated of any changes. I will notify the practitioner should I become pregnant of if I am
trying to become pregnant.
I understand the practitioner and administrative staff may review my medical records and reports, but
all of my records will be kept confidential and will not be released without my written consent.
I have read and understand this consent to treatment. I have been informed about the risks and
benefits of holistic therapy procedures. I intend this consent form to cover the entire course of
treatment for my present condition and for any future conditions for which I seek treatment.
I consent and understand that I may discontinue a session or sessions at any time. If I have been
diagnosed by a licensed health professional as having any disease, injury or other physical or mental
condition, I understand that I should inform the person who made the diagnosis, about the session I will be receiving, and whether or not I intend to discontinue any treatment or therapy which had been
previously ordered, prescribed or recommended by a licensed health professional. I understand that
by discontinuing any such treatment or therapy, I assume responsibility for any negative outcome
resulting from discontinuing that treatment or therapy. I, the undersigned, hereby confirm that the
information provided above is true and accurate to the best of my knowledge. I understand that the
practitioners at La Luna SoL are not medical providers, and their services do not
replace the advice or treatment of a qualified healthcare professional. I acknowledge that I am
responsible for informing the practitioner of any changes to my health status.