Wellness Center Intake Form

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Emergency Contact

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Insurance Information

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Adjunctive Care

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Health Concerns

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Pain Scale

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Practitioner Notice to Client:

All clients & patients(herein clients) of the Sickle Cell Foundation of Georgia(herein SCFG) and/or the Sickle Cell Sanctuary Integrative Wellness Center(herein SCS) or any of its satellite centers across the state of Georgia, who makes uses of & register via this patient portal, whether online, in person or by any other means, & who uses any portion of this website and/or the services provided by the SCS, are herein legally abound to, understand, and agree to all of the following:

All practitioners of the Sickle Cell Sanctuary Integrative Wellness Center are independent contractors & are not employees of the SCFG or the Sickle Cell Sanctuary, herein SCS.

While our healthcare practitioners and counselors are equipped and trained to provide the best innovative Integrative healthcare & wellness solutions, according to their training, expertise, certifications and/or licensures, the SCFG/SCS make no guarantees, expressed or implied, in regards to the success or effectiveness of any natural health therapies, modalities, or herbal, nutritional, homeopathic, naturopathic, or Traditional Chinese Medicine made available or recommended to you, our clients(herein client) for preventative or healing purposes, whether it be early or advanced staged chronic imbalances, as each individual circumstances are different, unique and complex and there are different factors that play a role in the effectiveness(or lack thereof) of any integrative and natural health therapy plan.

You understand & agree that there are risks associated with using and taking herbal medicine supplements, & that the risk are higher for the support and care of advanced staged life threatening health, chronic health & mental health imbalances, and your condition may or may not improve. Natural does not automatically mean safe, yet we will always exceed expectations to ensure the safety & well-being of all clients of the SCS.

You understand & agree that while we only recommend and prescribe clinically tested herbal medicines/supplement Rx manufactured through registered pharmacies certified & authorized by FDA, cGMP, & NSF compliant manufactures, pharmacies and dispensaries, that some Naturopathic, Homeopathic/Homotoxicology & TCM/supplements, that may have evidence based history of being very effective in addressing acute & chronic conditions, are alcohol based (tinctures), therefore you are responsible for disclosing all necessary health history information to the relevant practitioner during your consult visit, whether in-person or via telehealth.

Furthermore, some supplements, that may be effective in helping to improve your quality of life or heal your health imbalances, can potentially put stress on the kidneys and/or liver and has the potential to cause some adverse mild to moderate side-effects, and may require extra supervision, additional detoxifying supplements and/or periodic lab testing when taken long term.

You understand and agree that while under any nutritional &/or wellness therapy support plan, herein, prescribed by a practitioner of the SCS, under no circumstance should you use any OTC herbal supplements, homeopathic preparations or vitamin supplements either from online stores(i.e. ebay, Amazon, etc), local herb shops, Multi-Level Marketing schemes, or any patient direct sales business, or take any supplements that are not prescribed by either a SCS practitioner or another qualified licensed, Board Certified and/or registered healthcare practitioner with the relevant credentials to address specific& targeted healthcare needs(i.e. PCP or Specialists).

All allopathic prescription Rx prescribed by an MD or NMD, and/or Herbal, homeopathic, vitamin or any nutritional supplements being taken prior to your consultation, whether prescribed by a previous NMD, ND, OMD, or unqualified practitioner, etc., must be disclosed.

Failure to adhere to these terms, & failure to disclose all prior health history information when completing the patient portal or during your consult, can & will void your entire consult & therapy plans.

Furthermore, you understand and agree that you hold harmless and indemnify our practitioners from any claims of liability, lawsuits, judgements &/or warrant for any errors made during any consults, the creation of any therapy plans, or any natural medicine Rx prescribed in error, as a result of you, the client, withholding & failing to disclose all relevant health history information, and/or not disclosing all prescriptions, herbal medicines, & supplements being used prior to and while under the care and support of the SCS.

You, as an informed client, have the right to reject any therapies, supplements or regimens we give as a solution to support your optimal health. Our practitioners also reserve the right to refuse and/or withdraw our services at anytime, and for any reason, should they feel that they are unable to provide the best, safest, and effective quality Integrative care for your unique situation, health & mental health imbalances. All options and solutions will be thoroughly explained as to the effects, risks, expectations and general usage based on published studies & info made available from the manufacturers and other clinical journals, when necessary. We will not exaggerate or make un-substantiated claims or use any deceptive sales tactics in regards to our services. We will strive to be upfront and frank about our services, our qualifications, expertise and all expectations, as we believe in being honest, real, yet compassionate, warm, loving and maintaining integrity in our relationship with our clients(You).

You also understand & agree that while some practitioners are licensed Medical Doctors(MDs), Registered Nurses & Nurse Practitioners, our Integrative Wellness services are not the practice of allopathic medicine, nor do our practitioners, not licensed under the State of Georgia, imply at any time that they practice medicine under the laws of the State of Georgia. Our regulated holistic health specialties, are not to be confused with Allopathic Medicine & Family Medicine, Nutritional Counseling is not to be confused with Dietetics and Registered Dieticians(RD) and Bio-puncture is not to be confused with the practice of Acupuncture.

I acknowledge and voluntarily consent to receiving Holistic/Integrative Wellness Care & Support as a client through private expressive association, and not as a medical patient.  I further understand that the SCS & its practitioners are not practicing allopathic medicine, unless licensed by the State of Georgia to do so, & offers its services as & Holistic Healing and does not diagnose, treat, cure or prevent any disease as defined by the Food and Drug Administration and American Medical Association.

I acknowledge that I understand all of the risks associated with receiving said services and that I have reviewed all of the qualifications and expertise of said practitioner(s).

I have disclosed all existent medical & mental health conditions, known food allergies, prescription medications, and/or supplements being taken or prescribed to me by any other Doctor or practitioner, or of which I’ve purchased OTC, during the registration of my health portal, regarding my health history information, prior to and during any consultation session.

I understand that any herbal supplements, regimen and therapies I receive and take, based on any Wellness Consultation via the SCS is explicitly voluntarily consented to   at   my   own risks and conscientious choice.

I conscientiously release, hold harmless, and indemnify the SCFG & the SCS and its independent contractors, practitioners, counselors, and officers from any and all liability arising out of receiving said services.

By signing this form, I hereby expressly agree, covenant, and undertake the indemnification of, and does hold harmless, SCFG, SCS  and its Practitioners & officers from and against any and all claims, debts, legal actions, citations, orders, warrants, judgments, awards, demands, liabilities, losses, depositions, summonses, lawsuits, costs,  fines,  liens, levies,  penalties,  and  damages  and  action  whatsoever  in  any  manner arising from or growing out of said Integrative health, wellness  consultations and recommendations from  said practitioners.   I further agree that all claims, disputes, lawsuits, and matters of grievances and losses incurred by/from any licensed practitioners due to negligence, accidents, abuse or any other controversy, shall be resolved via mediation &/or binding arbitration proceeding, chosen by the SCS, for disposition and judgments. The arbitrator's decision shall be final and binding, and judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. I agree that any arbitration proceeding shall be conducted on an individual basis and not as a class, collective, or representative action. I hereby waive any right to participate in any class action lawsuits against SCS, SCFG or any of its practitioners. I also waive any right to a trial by jury in any action arising out of use of said Integrative Wellness services.

 I also agree that any grievance or lawsuits I may wish to bring against a practitioner or officer of the SCS/SCFG, at any time, to accept the SCS/SCFG, its practitioners or officers as “secured party” to all proceedings and to pay all attorney’s fees, expenses and losses for such litigation. The laws of the State of Georgia shall govern this agreement and all subsequent agreements & contracts made & arising out using said services.

SCS/SCFG explicitly reserves all rights, without prejudice