Intake forms, Directions, and Cancellation Policy

​Jane Smolnik, N.D., Iridologist, C.I.H., M.H.
Phone 828-777-JANE (5263)   drjanesmolnik@gmail.com   www.UltimateHealing.com

For all Holistic Health Consults ONLY:

 

INTAKE FORMS FOR HEALTH CONSULTS or COACHING

please click on the BioChemistry Health Questions,

fill out the interactive form 24 hours before our appointment to save us both time and money.

Direct Links to: 

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PLEASE NOTE:  It is NOT necessary to fill out the forms for BioField Clearing,

Transformational Intutive Analysis, or Vibrational Analysis.

For ALL PHONE CONSULTATIONS:

PLEASE CALL my conference call line at the time of our appt. so I can record it for you.

339-209-6298.  Thank you!

 

CANCELLATION POLICY - Please read!

 

You may cancel or change your appointment time up to 24 hours in advance.  Last minute changes or 'no-shows' will be responsible for HALF the fee for the service time scheduled (unless it is an emergency). 

Payment is expected at time of service by either cash, check or credit card.  

We like to be prompt to respect your time scheduled as well as ours.  Please be prompt since this is the only time allotted for you.  If you are late, you will be missing part of your appointment.  

PLEASE NOTE:  Most all consultations are via Phone or Zoom meetings at this time, unless otherwise arranged.  Thank you for understanding.

 

Please Call if you have any questions. Ph: 828-777-5263

 CLIENT INFORMED CONSENT & STATEMENT OF INTENT

I, Jane Smolnik, am a Traditional Naturopath and Iridologist. I hold a doctorate in Natural Medicine from Trinity College of Natural Health, I am a Diplomat in Holistic Iridology, Certified in Comprehensive Iridology, a Master Herbalist, a Certified Holistic/Spiritual Healer, and certified Instructor for Solas Academy. I have worked consistently in the field of nutrition and health education since 1990. I am a Health Educator/Coach, NOT A LICENSED PHYSICIAN. As such, I do not diagnose or treat disease, nor do I recognize disease. I also cannot and will not tell you not to take a medication your doctor has prescribed but we can discuss it. Rather, I help educate you and support the innate healing response of the body through food, nutrition, relaxation & visualization, herbs and supplements, nutritional balancing, energy/light/vibrational therapies, and stress reduction. 

I, the Client, understand that information provided on the relationship between nutrition and health is NOT meant to replace competent medical care or treatment for any health problem or condition. I understand that a Comprehensive Assessment and Health Evaluation are not done to define health as it relates to disease, but as it relates to wellness. 

I fully understand that the attending practitioner does not offer allopathic drugs, surgery, chemical stimulants, radiation therapy or any other conventional treatments. In addition, he/she does not diagnose, treat or otherwise prescribe for my disease, conditions or illness. I am advised to see my licensed healthcare provider for medical care. 

I, the Client, choose to improve my health by assuming greater self-responsibility to reduce or eliminate unhealthy behaviors that are contrary to my well-being. I am here to educate myself on how to take better care of my body naturally for greater health. 

I certify that I am here solely on my own behalf. I am not representing any other person, company, association, and/or on the behalf of any governmental agency. 

I currently am___ /am not____ under the care of a physician for a health problem or medical condition. If so, for what problem or condition? 

My physician is: ________________________________________________________________________________ 

                      (You will be asked to sign this informed consent form as part of your intake forms.)