New Clients: Please print out, initial box below, sign & date and fax to 518.483.4823 or mail to Edward Blomgren, Ph.D., Postal Box 123, Owls Head, NY 12969
Important Medical Disclaimer and Informed Consent
This website, the book and articles I've written, and all stop-smoking coaching (hereafter, "Information") is intended to educate you about how to stop smoking and quit tobacco with methods derived from the field of naturopathy and allied sciences, and to encourage you to make healthy choices in wellness. Although I’ll propose a course of naturopathic intervention for you, and provide you information to review and educate yourself, the decision to proceed or modify your plan will always rest with you and your health care provider! My role as a coach is that of an educator. It is up to you¾your body, mind and spirit¾to heal from tobacco; it is not up to me or anyone else.
All Information is provided with the understanding that I am not liable for any misconception, misuse or use of the Information nor am I, as a coach, engaged in the practice of psychology, counseling, medicine, offering medical advice, or curing any disorders or diseases. As a coach, I am simply providing information available in the public domain and scientific literature. I leave the final choice of what information to use up to you and your health care provider. My coaching is limited to providing information, sharing experiences, and empowering you to make your own choices for health.
Considerable effort has been made to make this Information as complete and as accurate as possible. Again, the purpose of this Information is to educate you to make your own choices; the Information is not intended to treat or cure any disease or disorder. I shall have neither liability nor responsibility to any person or entity with respect to any loss, damage or injury caused or alleged to be caused directly or indirectly by the Information provided, or any use thereof. The Information presented herein, and stop-smoking coaching, is in no way intended as a substitute for medical and psychological counseling nor to be construed as the practice of medicine or offering of medical advice.
If you do not have one already, you are encouraged to seek the partnership of a qualified health care practitioner of your choice, such as a naturopathic or an allopathic physician, before coaching or using Information I provide. When I coach you for tobacco cessation I will collaborate with your physician or other health care provider, at no additional charge to you, in order to insure the appropriate medical supervision from your own health care provider.
If you have any special conditions requiring attention (medical, psychiatric or psychological), you are advised to consult with your health care practitioner regularly regarding possible modifications of the Information contained in my book and via coaching, and collaborate with your health care provider. [Consent Version 1.0]
Please initial one box only:
□ Yes, I do want you, my coach, to collaborate with my health care provider. His/her name, address, and telephone is :
Name
Address
Telephone & Fax
□ No, I do NOT want you, my coach, to collaborate with my health care provider. I feel comfortable making my own decisions and will consult my health care provider when I feel the need.
By signing and dating this legal document, I [the ‘Client’] acknowledge that I have read—completely and in its entirety—the above Disclaimer and Informed Consent, have had all my questions answered to my satisfaction and understand and agree to the terms and conditions above, and hereby give my informed consent for coaching, without reservation.
Your data:
Name
Address
Telephone & Fax
cc: Client will be provided a signed copy
Coach records
FAX to 518.483.4823, OR mail to
Edward R. Blomgren, Ph.D.
Postal Box 123
Owls Head, NY 12969