Client Agreement, Informed Consent, Assumption of Risk, and Release
Practitioner: Gary Hopkins, Holistic Health Practitioner / Herbal Practitioner
Business: Finding Source
Business: Finding Source
> By checking the acknowledgment box on the New Client Forms, entering my full legal name, and submitting the New Client Form, I confirm that I have read, understand, and voluntarily agree to this Client Agreement, Informed Consent, Assumption of Risk, and Release.
1. Nature and Scope of Services
Gary Hopkins provides non-medical holistic wellness education, herbal education, lifestyle and self-care support, energy-based wellness services, and other complementary wellness services as mutually agreed. Services may include discussion of wellness goals, health history, nutrition, herbs, supplements, lifestyle practices, energetic approaches, bodywork, cupping, PEMF, and other non-medical wellness modalities.
These services are educational and supportive in nature. They are not medical, nursing, chiropractic, psychological, psychiatric, physical therapy, massage therapy, dietetic, or other licensed health-care services unless expressly identified as being provided by an appropriately licensed professional within that professional’s lawful scope of practice.
Gary Hopkins provides non-medical holistic wellness education, herbal education, lifestyle and self-care support, energy-based wellness services, and other complementary wellness services as mutually agreed. Services may include discussion of wellness goals, health history, nutrition, herbs, supplements, lifestyle practices, energetic approaches, bodywork, cupping, PEMF, and other non-medical wellness modalities.
These services are educational and supportive in nature. They are not medical, nursing, chiropractic, psychological, psychiatric, physical therapy, massage therapy, dietetic, or other licensed health-care services unless expressly identified as being provided by an appropriately licensed professional within that professional’s lawful scope of practice.
2. No Medical Diagnosis, Treatment, or Guarantee
I understand that Gary Hopkins is not a medical doctor and does not diagnose, treat, cure, prevent, mitigate, or prescribe for any disease, injury, medical condition, mental-health condition, or psychological condition.
No information, discussion, educational material, wellness suggestion, herbal information, supplement information, energetic service, or other service provided is intended to replace medical diagnosis, treatment, medication, emergency care, psychotherapy, or the advice of a licensed physician or other qualified health-care professional.
I understand that I am solely responsible for my health-care decisions, including deciding whether to use, change, discontinue, or avoid any wellness practice, herb, supplement, product, or information discussed.
I understand that no outcome, result, improvement, healing, or benefit is promised or guaranteed.
I understand that Gary Hopkins is not a medical doctor and does not diagnose, treat, cure, prevent, mitigate, or prescribe for any disease, injury, medical condition, mental-health condition, or psychological condition.
No information, discussion, educational material, wellness suggestion, herbal information, supplement information, energetic service, or other service provided is intended to replace medical diagnosis, treatment, medication, emergency care, psychotherapy, or the advice of a licensed physician or other qualified health-care professional.
I understand that I am solely responsible for my health-care decisions, including deciding whether to use, change, discontinue, or avoid any wellness practice, herb, supplement, product, or information discussed.
I understand that no outcome, result, improvement, healing, or benefit is promised or guaranteed.
3. Medical Care and Emergencies
I understand that I should consult an appropriately licensed physician or other qualified health-care professional regarding symptoms, injuries, illnesses, medications, diagnoses, pregnancy, allergies, mental-health concerns, or other health-related questions.
I agree to seek immediate emergency medical assistance by calling 911 or contacting emergency services for urgent or potentially life-threatening symptoms, including but not limited to chest pain, difficulty breathing, signs of stroke, severe allergic reaction, suicidal thoughts, severe bleeding, or loss of consciousness.
I agree to disclose relevant health information, including current diagnoses, medications, allergies, pregnancy status, implanted devices, recent surgeries, injuries, and any other condition that may affect the safety or appropriateness of services.
I understand that I should consult an appropriately licensed physician or other qualified health-care professional regarding symptoms, injuries, illnesses, medications, diagnoses, pregnancy, allergies, mental-health concerns, or other health-related questions.
I agree to seek immediate emergency medical assistance by calling 911 or contacting emergency services for urgent or potentially life-threatening symptoms, including but not limited to chest pain, difficulty breathing, signs of stroke, severe allergic reaction, suicidal thoughts, severe bleeding, or loss of consciousness.
I agree to disclose relevant health information, including current diagnoses, medications, allergies, pregnancy status, implanted devices, recent surgeries, injuries, and any other condition that may affect the safety or appropriateness of services.
4. Risks and Client Responsibility
I understand that wellness and complementary modalities may involve known or unknown risks, including temporary discomfort, soreness, skin irritation, bruising, emotional responses, aggravation of symptoms, allergic or adverse reactions, and unforeseen effects.
I understand that herbs, supplements, foods, topical products, wellness devices, touch-based services, energetic practices, and lifestyle changes may not be appropriate for every person and may interact with medications or health conditions. I agree to consult my licensed medical provider and/or pharmacist before beginning or changing herbs, supplements, diet, exercise, or other wellness practices, particularly if I am pregnant or nursing, have a medical condition, take prescription or over-the-counter medication, or am under medical care.
I voluntarily choose to participate in services and assume responsibility for all risks that may arise from my participation, except to the extent prohibited by applicable law.
I understand that wellness and complementary modalities may involve known or unknown risks, including temporary discomfort, soreness, skin irritation, bruising, emotional responses, aggravation of symptoms, allergic or adverse reactions, and unforeseen effects.
I understand that herbs, supplements, foods, topical products, wellness devices, touch-based services, energetic practices, and lifestyle changes may not be appropriate for every person and may interact with medications or health conditions. I agree to consult my licensed medical provider and/or pharmacist before beginning or changing herbs, supplements, diet, exercise, or other wellness practices, particularly if I am pregnant or nursing, have a medical condition, take prescription or over-the-counter medication, or am under medical care.
I voluntarily choose to participate in services and assume responsibility for all risks that may arise from my participation, except to the extent prohibited by applicable law.
5. Touch, Bodywork, and Personal Boundaries
If I receive a service involving touch, bodywork, cupping, a wellness device, or work performed on or near my body, I consent to appropriate touch and application of the agreed wellness modality. I understand that I may decline any technique, request modification, ask questions, or end a session at any time.
I agree to promptly inform Gary Hopkins if I experience pain, discomfort, distress, dizziness, numbness, skin irritation, or any other concern during or after a session.
If I receive a service involving touch, bodywork, cupping, a wellness device, or work performed on or near my body, I consent to appropriate touch and application of the agreed wellness modality. I understand that I may decline any technique, request modification, ask questions, or end a session at any time.
I agree to promptly inform Gary Hopkins if I experience pain, discomfort, distress, dizziness, numbness, skin irritation, or any other concern during or after a session.
6. Release of Liability and Indemnification
To the fullest extent permitted by applicable law, I voluntarily release, waive, discharge, and hold harmless Gary Hopkins, Finding Source, and their owners, employees, contractors, agents, successors, and assigns from claims, demands, causes of action, damages, costs, or liabilities arising out of or related to my voluntary participation in services, my use or misuse of information, or my decision to use or not use any wellness practice, product, herb, supplement, or recommendation discussed.
This release includes claims based on ordinary negligence to the extent allowed by law. It does not apply to conduct that cannot legally be waived.
I agree to indemnify and hold harmless the released parties from third-party claims arising from my own acts, omissions, inaccurate information, or violation of this Agreement.
To the fullest extent permitted by applicable law, I voluntarily release, waive, discharge, and hold harmless Gary Hopkins, Finding Source, and their owners, employees, contractors, agents, successors, and assigns from claims, demands, causes of action, damages, costs, or liabilities arising out of or related to my voluntary participation in services, my use or misuse of information, or my decision to use or not use any wellness practice, product, herb, supplement, or recommendation discussed.
This release includes claims based on ordinary negligence to the extent allowed by law. It does not apply to conduct that cannot legally be waived.
I agree to indemnify and hold harmless the released parties from third-party claims arising from my own acts, omissions, inaccurate information, or violation of this Agreement.
7. Confidentiality and Records
Gary Hopkins will make reasonable efforts to keep my information private and confidential. Information may be used or disclosed only as reasonably necessary to provide services, operate the business, process payment, comply with legal obligations, respond to a valid legal process, protect against a serious safety concern, or with my written permission.
I understand that Gary Hopkins is not representing that services or records are covered by HIPAA unless separately stated in writing.
For professional consultation, education, or supervision, non-identifying information may be discussed with professional peers or mentors when reasonably necessary, without using my name or identifying details whenever practicable.
Gary Hopkins will make reasonable efforts to keep my information private and confidential. Information may be used or disclosed only as reasonably necessary to provide services, operate the business, process payment, comply with legal obligations, respond to a valid legal process, protect against a serious safety concern, or with my written permission.
I understand that Gary Hopkins is not representing that services or records are covered by HIPAA unless separately stated in writing.
For professional consultation, education, or supervision, non-identifying information may be discussed with professional peers or mentors when reasonably necessary, without using my name or identifying details whenever practicable.
8. Fees, Cancellations, and Termination
I agree to pay all fees due before or at the time of service unless another written arrangement is made. I understand and agree to the current cancellation, no-show, refund, and scheduling policies posted by Finding Source or otherwise provided to me.
Participation is voluntary. I may discontinue services at any time. Gary Hopkins may decline, pause, or discontinue services when appropriate, including when services are outside the practitioner’s scope, when medical or mental-health referral is appropriate, or when client safety or professional boundaries require it.
I agree to pay all fees due before or at the time of service unless another written arrangement is made. I understand and agree to the current cancellation, no-show, refund, and scheduling policies posted by Finding Source or otherwise provided to me.
Participation is voluntary. I may discontinue services at any time. Gary Hopkins may decline, pause, or discontinue services when appropriate, including when services are outside the practitioner’s scope, when medical or mental-health referral is appropriate, or when client safety or professional boundaries require it.
9. Electronic Consent and Signature
I agree to conduct this transaction electronically. I understand that checking the acknowledgment box, entering my name, and submitting this form constitutes my electronic signature and has the same effect as a handwritten signature.
I represent that I am at least 18 years old and legally able to enter into this Agreement. If services are for a minor, a parent or legal guardian must complete and sign this Agreement and remains responsible for the minor.
I agree to conduct this transaction electronically. I understand that checking the acknowledgment box, entering my name, and submitting this form constitutes my electronic signature and has the same effect as a handwritten signature.
I represent that I am at least 18 years old and legally able to enter into this Agreement. If services are for a minor, a parent or legal guardian must complete and sign this Agreement and remains responsible for the minor.
10. Governing Law and Severability
This Agreement is governed by the laws of the State of Ohio, except where another jurisdiction’s non-waivable law applies. If any provision is found unenforceable, the remaining provisions will remain in effect to the fullest extent permitted by law.
This Agreement is governed by the laws of the State of Ohio, except where another jurisdiction’s non-waivable law applies. If any provision is found unenforceable, the remaining provisions will remain in effect to the fullest extent permitted by law.
