I understand that the SHAPE Program is a lifestyle modification and health restoration program designed to help me improve my overall health. This program is not intended to replace the guidance of my primary healthcare experts. While this program is not used to diagnose, treat, cure or prevent any disease, I understand any medications I am currently taking may need dose adjustments. I agree to notify my prescribing physician that I am working with a Shape Reclaimed Practitioner and will be closely monitored while incorporating this program for embracing a healthier lifestyle. I understand an anti-inflammatory nutrition protocol will be recommended based on my unique health history, urinalysis and symptoms.

We understand that our intent and responsibility is to determine if the SHAPE Program would be beneficial for assisting your body in its innate healing process. Our first 2 appointments with you will be multi-faceted. We agree to do the following: Take full health history and assess your unique needs. Discuss your health goals. Perform a baseline urinalysis. Make specific recommendations as necessary (nutrition, supplements). Determine a follow-up schedule.

I will notify my prescribing physician that I am working with a SHAPE Practitioner and will be closely monitored while incorporating this program.

I have been informed and understand that nutritional and lifestyle recommendations may involve certain risks. These may include, but are not limited to, detoxification symptoms, such as: initially feeling worse due to the release of stored toxins, digestive symptoms, fatigue, headaches, muscle or joint pain, allergic reactions or any unpredictable reaction with my prescribed medications that has not been found in research literature. I agree to subit a full health history, discuss my health goals, have consistent urinalyses and follow-up visits as recommended by my SHAPE practitioner, read the Program Guidebook, review the information provided on the SHAPE ReClaimed website, and be aware that I can join the “OFFICIAL SHAPE ReClaimed Support Group” on Facebook and will not substitute recommendations from Facebook for my specific health needs.

I understand that if I am on any medications, I have been advised to consult my prescribing physician with regards to dosage reduction and/or elimination as my physiology changes during the SHAPE Program. I agree to follow the guidelines of the program in order to achieve the best results.

At Living with Elevation Natural Health Center, we DO NOT prescribe or “un-prescribe” any pharmaceutical medications. All dosing of your prescription medications must be done through the doctor who prescribed them for you.

This office is NOT an approved direct provider to insurance companies. As such, we do not provide a Medical Necessity letter to any insurance companies for reimbursement of services or products.

Your records will stay on file for 12 months after your last office visit at which time they will be destroyed.

Your appointments and well-being are very important to us. We understand that sometimes, unexpected delays can occur, making schedule adjustments. If you need to cancel your appointment, we respectfully request at least 24 hours notice.
• Any cancellation, no-show or reschedule made less than 24 hours will result in a cancellation fee. The amount of the fee will be equal to 50% of the reserved services or $30, whichever is more.
• If you are more than 5 minutes late for your service, we may not be able to accommodate you. In this case, the same cancellation fee will apply. We will do our very best to reschedule your service for another time that is convenient to you.
• We may require a credit card to hold your appointment. Cancellation fees will be charged to your card on file.
In the event of a true, unavoidable emergency, all or part of your cancellation fee may be applied to future services.

I understand it is my responsibility to notify the practitioners at Living with Elevation Natural Health Center of any changes to the above safety concerns prior to my visit.

I understand that none of the methods used in our office are for diagnosing or treating any known or unknown disease including conditions such as cancer, aids, infections or other medical conditions and that these are not being tested for or treated.