The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us. We understand that your medical information is personal and we are committed to protecting it. We will not use or disclose your medical information for any purpose without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice.
Karen Langston, LLC
Consent and Disclaimer Form with Constructive Notice Addendum
I , hereby attest to the following: I request that Karen Langston perform an evaluation and interview and set up a program for the purpose of educating on reducing stress, and enhancing my health.
I understand that Karen Langston has a degree in Holistic Nutrition, from The Institute of Holistic Nutrition, in Toronto, Canada; Early Childhood Education, from Centennial College, in Toronto, Canada. Somatherapies, in Florida, USA; and First Line Therapy in Arizona, USA. I understand that Karen Langston holds in good standing her registry and Professional Membership with the National Association of Nutrition Professionals. I also understand that therapy, guidelines, consultation, and education, is not intended as diagnosis, prescription, or treatment for any disease, physical or mental. It is also not intended as a substitute for medical care. I also understand that it is my responsibility to consult with my primary health care practitioner before starting any type of weight loss strategy and cannot hold Karen Langston accountable for the education provided.
I am here, on this and any subsequent visit, solely on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation.
I fully understand that Karen Langston is not a medical doctor and I am not here for medical diagnostic or treatment procedures. I understand that I must seek medical advice from my medical doctor.
The services provided by Karen Langston are at all times restricted to consultation on the subject of nutritional matters intended for general nutritional well-being and do not involve the diagnosing, prognosticating, treatment, or prescribing of medication for the treatment of any disease, or any licensed or controlled act which may constitute the practice of medicine in this State or Province.
I intend to use all or some of the activities services and programs offered by Karen Langston. I understand that this program is educational, recreational and self-directed in nature. I assume full responsibility during and after my participation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive. I declare that I have read understood and agree to the contents of this informed consent agreement in its entirety.
Any medical questions are to be directed to my physcian and will not be answered by Karen Langston.
NINTH AMENDMENT, U.S. CONSTITUTION
“The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage other retained by the People.”
Under the Ninth Amendment to the Constitution of the United State of America, I retain the right to freedom of choice in health care (or psychological services, or educational services, etc….) This includes the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy or product recommended by the therapist, doctor or any practitioner of my choice.
The enumeration in this declaration of these rights shall not be construed to deny or disparage other rights retained by me, or my rights to amend this declaration at any time.
Notice is hereby given to any person who receives a copy of this Declaration and who, acting under color or law, intentionally interferes with the free exercise of the rights retained by me under the Ninth Amendment, as enumerated in this declaration that they may be in violation of my civil and constitutional right. (Electronic copy: filling out and emailing to Karen Langston substitutes a signature and is held as confirmation of agreeing to the above.
Before begining this program or any other program is expected of you to seek medical approval and to discuss and disclose this program and any supplementation with your doctor.
State law allows any person to provide nutritional advice or give advice concerning proper nutrition – which is the giving of advice as to the role of food and food ingredient, including dietary supplements. This state law and Karen Langston LLC does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is licensed health practitioner to state that any product might cure any disease, disorder, or condition.
I am solely responsible for the decision to see Karen Langston for Nutritional Therapy. I recognize that some recommendations may not prove to be successful. I understand some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concerns to Karen Langston. I also understand that any significant symptoms should be reported to my doctor. It is also recommended that I discuss the use of any nutritional supplements with my doctor before implementing.