Agreement Form

First name

Last name

Email

Phone

Emergency Contact

Birthday

Month

Day

Year

Have you been hospitalized in the last 12 months?

Yes

No

Are you suffering from any medical condition, illness, or injury?

Yes

No

Are you on any medications?

Yes

No

If you answered yes to any of the questions above, please supply additional information.

What is your reason for booking a Mini Consult with Sherri? Write the acute issue you are currently dealing with.*

Additional Information

Waiver & Consent to Services

I agree to continue regular care with licensed healthcare providers.

I understand Restored Wellness provides holistic wellness services only.

I understand these services do not diagnose, treat, or cure medical conditions.

I understand no outcomes or results are guaranteed.

I accept full responsibility for my wellness decisions.

I release Restored Wellness from any liability connected to the services provided.

I declare that the info I’ve provided is accurate and complete. By signing below, I acknowledge I have read and understand this agreement and voluntarily consent to receive holistic wellness consultations.

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Waiver & Consent to Services