Hormone Test Kit Registration

I hereby authorize SourceEnergetix, LLC (I Am Well Today) “Clinician/Physician(s)”, associates, and employees to provide services to me / my child and to perform any necessary tests which, in Clinician/Physicians judgment, may be advisable.

I understand that I have an opportunity to ask questions and understand that the Clinician/Physician’s responses should be satisfactory to me prior to agreeing to protocol.

I understand that medicine is not an exact science and that all possible outcomes and/or complications cannot be anticipated and that no implied or expressed promises or guarantees will be made. I further understand that some of the medical therapies recommended by Clinician/Physician may be innovative, and not yet generally accepted in the medical community, and might not be supported by clinical research.

In consideration for services rendered or to be rendered to me/my child by Clinician/Physician, I hereby assign to Clinician/Physician and authorize payment directly to Clinician/Physician of any insurance benefits or other payments by third parties otherwise payable to me. I understand I am financially responsible to Clinician/Physician for all charges related to services provided, and not directly covered by my insurance.

I specifically acknowledge that no guarantees of any kind have been made to me as to course, duration, or result of the recommendations and protocols. I give this general consent voluntarily on my behalf or on behalf of my child, for whom I am the legal representative. I come to this arrangement as an informed consumer specifically seeking natural and alternative approaches from SourceEnergetix Clinician/Physicians. I hereby authorize SourceEnergetix through its appropriate personnel, to perform assessment and testing procedures on the below named patient.

I understand that assessments and products given by SourceEnergetix are not intended to take the place of a comprehensive medical evaluation and you are advised to take the suggestions provided here to your primary care physician for review and approval before proceeding to put any suggestions into effect. The clinicians sponsored by SourceEnergetix cannot and will not make a diagnosis, prescribe medication, order diagnostic studies for you or participate in any manner other than as an educational resource. Any treatments suggested such as taking nutritional supplements should be checked with your medical doctor first to determine if they are compatible with your medical situation. Nothing discussed here is intended to diagnose, prevent, or treat and disease or disorder.
Further, the undersigned releases SourceEnergetix, lab partners, independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their services.

The kit provided for the saliva sample is non-refundable through SourceEnergetix. In the event that the kit is misplaced, we will assist for a replacement kit, but do not guarantee that we not charge an additional fee. I authorize SourceEnergetix to access my testing information for purposes of analysis and reporting. I understand that this data belongs to me and I can request to have that information transferred to me as long as there is not a balance for payment on my account.