Agreement for Remote Clients 1Agreement & Consent2Client Application3Health History4Medications & Substances5Vaccines, Dental & Exposures6Authorization & Signature ORGANIC HEALTH SYSTEMS CLIENT AGREEMENT5604 North Lee Highway, Fairfield, VA 24435 | (540) 460-2641organichealthsystems.com | info@organichealthsystems.comOnce you have filled out this form, if you want to order a telemedicine appointment, you can order the Level that you want online. If you want an in-office appointment, you can call or email the office.About Our PracticeBiophysics testing is a noninvasive method of gaining valuable information about your body's vital functions. The primary objective is to disclose patterns of stress and provide treatment via imprinted frequencies. The imprint drops we custom formulate give the exact dosages needed to balance each of the most causal energetic imbalances. We do not "diagnose" or "treat" clients but instead use imprints in a way similar to homeopathy.Organic Health Systems does not provide medical diagnoses, cure, prevent or treat disease and is not a medical office. OHS biophysics balancing is not a substitute for medical treatment — each client is responsible for their own health. If you suspect you need medical intervention, please consult your physician. OHS staff are not physicians. Any decision to follow through with the recommended program is your own — OHS and office staff shall be held blameless. You should continue to see any medical doctors you are currently under the care of, and any prescribed medication should not be altered without first consulting the physician who recommended it. OHS may at any time discontinue evaluations of any kind at its sole discretion.Telemed purchases/subscriptions or office visits are not interchangeable between family members and friends, nor are they refundable.Telemedicine (Remote Testing)Many clients opt for telemedicine appointments, which utilize hair samples for testing and include customized imprints used for 6 weeks. There are 3 different appointment levels. The cost for a one-time Level 2 telemed appointment is $289.00. Subscriptions are discounted (Level 2 Subscription is $279) and subscription clients have a reserved space in the testing schedule. Subscriptions run in blocks of 12 appointments — tests being run automatically/preventatively every 6 weeks. Subscriptions cancelled prior to that time will be charged a cancellation fee ($350). In the event of an emergency, subscriptions can be paused once a year for a 6-week cycle but must be resumed at that point. You must be a subscription client to order supplements.In-Office VisitsIn-office visits are $375.00. A $175.00 deposit is required to hold the appointment (nonrefundable). If the in-person appointment is missed, the full fee is charged. The client intake form must be fully completed prior to the appointment.ShippingThe client is responsible for collecting imprints from the post office. OHS is not responsible for imprints that have not been collected or have been misplaced by the postal service.Refunds, Cancellations and ReschedulingThere are no refunds on testing. Appointments may not be rescheduled or cancelled except in the event of an emergency. There are no refunds for cancelled appointments.Do you agree to the above statements?* I have read and agree to the above terms and conditions. Purchase Policy* I agree that all purchases are final and that there are no refunds. I agree that an executed photocopy or digitally or photographically archived copy of this document shall have the same force and effect as an executed original document. Accuracy of Information* I agree and swear under the penalty of perjury under the laws of the United States that all facts I provide in this form are true and correct. Imprint & Supplement Policy* I understand that to receive imprints and certain supplements I must be a current, active client currently on a 6-week schedule. I am: (please choose ONE)* Of the age of majority and am signing on my own behalf Signing (with permission) for a spouse or family member I am helping in this process Signing as a parent or guardian on behalf of a dependent Name of Dependent (if signing as parent/guardian)* APPLICATION FOR TESTINGOHS must have a separate, completed application for each individual.CLIENT — Person Receiving the TestingName of person completing this form (and relationship to client, if different)*Client Name (Person Receiving the Testing)* First Last Where did you hear about us, or who referred you?*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home Phone*Work Phone*Work Extension*Email Address* Age*Date of Birth* MM slash DD slash YYYY Birthplace (City & State)*Gender* Male Female Occupation*Blood Type (if known)* O A B AB Unknown Optional Comments Pertaining to Health*Upload a Photo of Yourself*Accepted file types: jpg, jpeg, png, Max. file size: 2 GB. OHS uses a photograph for remote energetic balancing. Photo should be of the applicant only — no other people or pets. Accepted: JPG, PNG.FINANCIALLY RESPONSIBLE PARTY (if other than applicant)Financially Responsible Party — Name* First Last Financially Responsible Party — Relationship to Applicant*Financially Responsible Party — Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Financially Responsible Party — Cell Phone*Financially Responsible Party — Home Phone*Financially Responsible Party — Work Phone*Financially Responsible Party — Work Extension*Financially Responsible Party — Email* PARENT OR GUARDIAN OR SPOUSEParent / Guardian / Spouse — Name* First Last Parent / Guardian / Spouse — Relationship to Applicant*Parent / Guardian / Spouse — Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent / Guardian / Spouse — Cell Phone*Parent / Guardian / Spouse — Home Phone*Parent / Guardian / Spouse — Work Phone*Parent / Guardian / Spouse — Work Extension*Parent / Guardian / Spouse — Email* HEALTH HISTORYPlease list your symptoms and how long you have been experiencing each one.*YOUR GOALS & CONCERNSWhat are your biggest concerns? What have the roadblocks been? How do you feel about setting a goal for yourself? Please share.* MEDICATIONSPrescription Medications*Medication NamePrescribed ForBeen on Since List all prescription medications. Click “Add Row” to add more.Over-the-Counter Medications*Medication NameFrequency of UseHave Taken Since List all OTC medications, even ones taken infrequently (e.g. Benadryl, Zyrtec, Advil, Tylenol, Nyquil, Claritin, Nasacort). Please be thorough.Alcohol, Smoking & Recreational SubstancesNote: We do not share this information without your permission. The purpose of this section is to help us separate accidental chemical exposures from intentional ones — not to pass judgment.Alcohol, Smoking & Recreational Substances*ItemFrequency of UseUsed Since Examples: alcohol (wine, beer, spirits), marijuana, CBD, cigarettes, vaping, chewing tobacco.Additional Notes on Medications or Substances* VACCINATION HISTORY & DENTAL PROCEDURESThis information helps us identify the degree of detoxification and energetic chelation needed.Do you routinely get vaccinated?* Yes No Vaccine History*Vaccine NameApproximate Date List vaccines received and approximate date. Examples: HPV, Pertussis, Tetanus, Shingles, Flu, MMR, Covid, RSV, etc.Dental Procedures (implants, root canals, crowns, amalgam fillings, etc.)*Work Environment & Chemical ExposuresDescribe your work environment and any vapors, chemicals, or exhausts you are exposed to — and whether exposure is frequent or rare. Examples: diesel fuel, gasoline, paint sprays, urethanes, chlorinated chemicals, solvents, metals, lead, mold, cleaning products, botox, fillers, GLP-1 peptides, breast implants, etc.Work Environment & Chemical Exposures* AUTHORIZATION TO SHARE INFORMATIONI understand that I must give written permission for my test results to be shared or discussed with others. Please list anyone authorized to receive or discuss your results with OHS.People Authorized to Receive / Discuss My Results*NameRelationshipPhone NumberEmail List up to 3 people. Leave blank if none.HAIR SAMPLE INSTRUCTIONSOHS uses hair samples for testing. You can mail a hair sample or drop it off at our office drop box. A few hairs taped with scotch tape and placed in a plastic baggie is sufficient. Mail to:Organic Health Systems, c/o Catherine CashP.O. Box 207, Fairfield, VA 24435Are you sending a hair sample?* Yes No SIGNATUREPrint Your Full Name* First Last Signature*Sign with your mouse, finger, or stylus.Date* MM slash DD slash YYYY
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