Disclosure to the client in plain, written language that: 

• That the practitioner is not a licensed physician; that the treatment is a complementary or alternative healing modality and not licensed by the state; the nature of the service to be provided and the theory of treatment upon which the services are based; and the practitioner's education and other training, experience, and other qualifications regarding the services to be provided. 

I understand that Dr. Daniel Wilczak is not a licensed physician in New Mexico and does not possess a license from the state of New Mexico. 

I can offer you these services described to you within the given consents, subject to requirements and restrictions that are described in this document. In practicing complementary and alternative healthcare Dr. Dan Wilczak seeks to support rather than replace the care of your existing doctors and practitioners. 

 

Educational Qualifications and Training to Practice Cupping Therapy, Active Release Therapy, IASTM, Fascial Movement Taping, Holistic Kinesiology: 

Cupping Therapy 

• 100 hour Cupping and Acupuncture Certification Logan University 2015 

Active Release Therapy 

• Certificate, Logan University 2016 

• IASTM 

Certificate, St. Louis MO 2016 . Fascial Movement Taping 

• Certificate, St. Louis MO 2016 

• Holistic Kinesiology 

• SFMA Cert 2016

 If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor, and/or other practitioners you are seeing and find applicable, that you are receiving these treatments. 

Please acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy upon request. I will keep the original in my records for at least three years. 

Acknowledgement and Consent to Receive Services: 

I have read and understand the above disclosure about the Services offered by Dr. Dan Wilczak and Dr. Dan Wilczak's training and education. I have discussed with Dr. Dan Wilczak the nature of the services to be provided. I understand that Dr. Dan Wilczak is not a licensed physician. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Dr. Dan Wilczak, and agree to be personally responsible for the fees of Dr. Dan Wilczak-in connection with the services provided to me. 

 

Signature of Client 

______________________                      Date_________________

  • Black Facebook Icon
  • Black LinkedIn Icon
  • Black Twitter Icon
  • Black Pinterest Icon