I hereby understand, agree, and attest to the following:
I fully understand that the practitioner I am seeing in this office is not a physician, and I am not
consulting for medical, diagnostic, or treatment procedures. The appointments do not involve the
diagnosing, prognosticating, treating or prescribing of medicines or the treatment of disease, or any
act which will constitute the practice of medicine in this state, for which a license is required.
The wellness plan offered may include discussion and or sale of nutritional supplements,
nutrition and lifestyle modifications, medicinal plant remedies, vitamins, minerals, food grade herbs,
and other dietary supplements.
Women who are pregnant or planning pregnancy must inform their Wellness Consultant, as this will
likely alter the recommendations that are made.
Since they are not prescribing physicians, the practitioner will not be able to advise me to discontinue
or change doses of my medications. I am advised to consult with my prescribing physician
concerning any modifications of my pharmaceutical medications.
There are wide individual differences in response to a wellness plan, and no guarantees are made
that I will gain any benefit nor experience any adverse consequences.
While I may experience immediate benefits from the wellness plan, I understand that the most
effective results will occur when I make a long-term commitment to my health.
I, the undersigned, hereby confirm that I am consulting with William Siff, L.Ac of my own free will, I assume
responsibility for any risks and hold William Siff free of liability. I understand that there will be no diagnosis
made, nor prescription given, but that the above named practitioner will offer an assessment of my general
health and will make dietary and herbal recommendations