Consent Form


Disclosures, Authorization, Records Release & Consent

Thank You for choosing to allow us to work with you. We consider it a privilege.

Arrowhead HealthWorks™ is a privately owned health consulting company founded in 1988 by Carolyn Bormann, N.D. We offer various services: In the US we provide Non-medical services and Medical is offered through our affiliate clinic in Tijuana, Europa Institute of Integrated Medicine (see website link for more clinic info). or one of our Network professionals in the US.

Carolyn Bormann, N.D. is a non-licensed Traditional Naturopathic Practitioner. She also holds special certificates in Phlebotomy and Lab Technology, Bio-Oxicative Medicine, Lymphology, Enzyme Therapy, Medical Hyperthermia, Hyperbaric Oxygen Therapy. We utilize extensively the incredibly gifted medical intuitive skills of Dr.Marvin McCormick, D.C. who is a Master Quantum Informational Specialist & Chiropractor with wide scope of experiences. A graduate from Cleveland Chiropratic College, he is the best in physiological palpation and manipulation of the entire body (not just spine) we've ever encountered in our 42+ years around Chiropractic. He is in great demand by physicians, chiropractors and other professionals for their own healthcare needs. We're privileged to have him be part of our on-call team.

Legal Disclosures: The information and outcomes gleaned through our services are not to be misconstrued as either directorly or indirectly dispensing medical advice for the cure or mitigation of any disease or condition since only a licensed physician can diagnose or prescribe for diseases. Our direct focus at our Wellness Center is non-medical therefore we do not participate in any insurance programs and neither do we carry malpractice insurance of any form.

WELLNESS CENTER: At our S.Calif. Mountain Wellness Center, we utilized an integrated approach using the best of Quantum Informational Techniques, Energy Medicine, Naturopathy, Chiropractic, etc. and we don't believe in limiting things to a "disease tag" which is based on old Newtonian science and strictly focuses on particles, chemicals, innanimate particle-based interactions. We work deeper at the level of photons and information which is the basis for Quantum Physics and precedes particles and matter to find the CORE issues that the body indicates are the most critical issues from reading the DNA information field. Of course we integrate Clinical Nutrition, Enzyme Therapy, Physiotherapy, Massage, Phototherapy, BioOxidative therapies, etc. We believe that pro-active Self Care is the best possible approach to long lasting results. See our webpage for more information Arrowhead Wellness Center

EUROPA CLINIC: We are currently the US Case Coordinator / Director for our affiliate Medical Clinic, Europa Institute of Integrated Medicine, located in Tijuana, BC Mexico is an Integrative Medicine clinic. It is located on the Mexican side of the San Diego/Mexico Border, just 500 yards from the Border gate. There we specialize in the treatment of Cancers, Chronic Infections, Autoimmune conditions, Cardiovascular Disease and other Chronic Conditions utilzing the best of Alternative (CAM) and Naturopathic methods from around the globe but especially European based. Many of the therapies and services are not available in the US currently due to medical/industrial complex policies and laws.
EUROPA CLINIC INFO.

Should medical or dental intervention be required and coming to our TJ clinic is not an option, and you do not have a competent CAM physician to work with, we can offer to work with one of our Network medical or dental referrals or refer directly if appropriate.

Our clients are typically independent thinkers and highly motivated responsible self-starters. They want to be actively involved in their health care and not passive. Therefore, it is important that you understand that in the event that you choose to utilize any of our services, suggested supplements, food regimens or programs suggested and/ or utilize our referral recommendations to other facilities or professional services that we believe could be helpful, you are prescribing for yourself, which is your 9th Amendment Right, but we assume no responsibility or liability for the outcomes. Healing is multifaceted as is life and there are no simplistic answers.

All known risks and benefits of any product, procedure, therapy, dietary changes, or tests will be explained to the best of our knowledge although it should not replace any research you should do also since information is constantly changing. We will take as much time as necessary to answer questions and make sure you understand everything so that you can make intelligent decisions, and we respect your right to self determination. No product or other purchases are required to utilize our services.

INFORMATION PRIVACY
All medical and personal information procured is confidential and will not be used, disclosed or sold to anyone else for marketing or commercial purposes, with the exception for Europa Clinic Applicants that pertinent medical information will be shared with Europa Clinic Physicians for case evaluation for treatment at their Tijuana Clinic.

CONSENT & RECORDS RELEASE
I, (type name) and I am voluntarily seeking the services of Arrowhead Healthworks™ and affiliates, services or products. I have read and understand the above statements and conditions. I agree and consent to work together proactively to build my health. I understand that I have options to consult with both licensed and unlicensed practitioners and therapists at my discretion as part of exercising my 9th Amendment Right to Self Determination, and that this is not a licensed medical practice but your services are designed to provide health building information and products and therapies and should I choose to use any of this information for self healthcare, I agree to hold Arrowhead Healthworks and their contract therapists and doctors harmless from any present of future liability.
I am 18 years old or older. I give permission and consent to procure and review my healthcare records, medical records, Lab and Xray or Diagnostic reports, and any other necessary paperwork required to assist you in the assessment of my current health status and in helping me determine what services may be appropriate for my benefit. I give permission for you to share pertinent medical and any other information necessary with therapists who will be directly involved in my care.

To the best of my knowledge, all these statements are true and factual.
I am over the age of 18 and able to make my own healthcare decisions. I am the fincially responsible party.
MINOR PATIENTS ONLY: I am the Parent of or have Power of Attorney for making healthcare and treatment decisions for the above named patient who is a minor or unable to make medical decisions.
(we'll need a copy of the notarized POA for our files)

Name: Telephone Date of Birth Year Address: City: State Zipcode

(Patient Virtual Signature ) (Guardian / Power of Atty Virtual Signature)
(Today's Date)

(909) 338-3533 / FAX (909) 338-3743
E-mail: dbormann@arrowheadhealthworks.com *ARROWHEADHEALTHWORKS.COM

Name:	Telephone	Date of Birth Year
Address:	City:	State Zipcode