INFORMED CONSENT AND LIABILITY WAIVER
Noble Root Herbs LLC
I ______________________ seeking health guidance, hereby attest to the following: (please initial each of the following) 1. I fully understand that Lana Hyatt of Noble Root Herbs (or if you are, indicate as such) is not a licensed medical doctor, does not diagnose or treat disease, and that I am not here for medical, diagnostic or treatment procedures. _____ 2. Suggestions and treatments offered for my own well-being and are not intended to take the place of qualified professional medical care, including the diagnosed treatment of named diseases. _____ 3. I understand that assessment and suggestions regarding diet, nutritional supplementation and herb/compounds or preparations, remedies, homeopathy, flower essences offered here or elsewhere are based upon the observations through Folk Remedy , Native American Herbal Medicine or Western Herbalism and Energy Healing are not intended to replace standard medical treatment or advice from licensed health care professionals. _____ 4. I agree that all nutritional supplements, herbs, extracts, remedies, etc. are taken at my own risk. As with any ingested substance, allergic reaction is a possibility in some individuals. I have been informed of the risks and consequences involved. I agree that I and my heirs, guardians, legal representatives and assigns will not make claim or file any action against myself or any members of Noble Root Herbs for injury or damage resulting from negligence or other acts, whatsoever, caused in connection with my consultation. I also understand that Noble Root Herbs will not be held responsible for errors/ ingredients on the part of any manufacturer or supplier of products offered here or elsewhere. ____ 5. I hereby consent to authorize Noble Root Herbs other alternative modalities that may be implemented upon reasonable assessment I have carefully read this agreement and fully understand the content. I am aware that this is a waiver and release of potential liability and a contract between Noble Root Herbs and myself and sign it of my own free will. Signature _____________________________________________________________ Date___________________________ Printed Name________________________________________ Address:___________________________________________ City ____________________ State ____________ Zip _________ Any telephone numbers where you can be reached:_________________________________________________________________ Email address for those who wish to be on our mailing list: __________________________________________________________ Herbalists/Healer’s signature ____________________________________________________ Date ___________________________ Any information shared in sessions is confidential and will not be disclosed to any party, be they family or medical provider. However, for educational purposes it may be shared anonymously with mentors and co-students. Occasionally we may ask if you would allow us to take your photograph during any of the personal sessions offered. These may be used
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P.O BOX 1263 Scottsdale AZ 85252
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