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This form is signed electronically here .


Roanne Bacchus
709 N Price Rd
Florence, SC 29506


Lifestyle Prescriptions® Consultation Consent Form


Prior to our first session, a client/patient must sign an informed consent form which includes notifications of the scope of practice, possible side effects, and a list of the practitioner’s education and qualifications. This consent form is designed to meet these requirements, as well as answer other questions you may have about Lifestyle Prescriptions® Health Coaching.


Alternative and Complementary Practitioners must inform clients that they are not Physicians and Surgeons or allied licensed practitioners and that for a western medical diagnosis and treatment, including, but not limited to, prescription drugs, surgery and the treatment of fractures, lacerations and abrasions, the clients must see an MD, Physician or Surgeon.


As a Lifestyle Prescriptions® Provider I’ll help you find the stress triggers, emotions, beliefs & lifestyle choices affecting your well-being and use a variety of health coaching techniques to guide you towards a healthier body-mind and life. I DO NOT diagnose or treat medical conditions or prescribe drugs or any type of medication or treatment. Lifestyle Prescriptions® solely focus on lifestyle modifications and habit change. I use holistic, non-invasive techniques such as Emotional Freedom Technique (EFT Tapping), Mirror Affirmations and other modalities.


I also offer ThermoBuzzer™ Mobile Imaging System which combines cutting-edge mobile technology with infrared imaging to visually demonstrate stress imbalances via the autonomic nervous system. It's the perfect educational and monitoring system for peak performance, longevity and prevention screenings. ThermoBuzzer™ is non-invasive, offers no contact or chemical including radiation. It indicates under/over function, blood flow, inflammation and imbalances caused by stress. My use of ThermoBuzzer™ is NOT for pathology or diagnosis.


By submitting this form you agree that you have read and understood the above statements and therefore accept care from Roanne Bacchus on this basis.


Typing your full name and submitting this form will serve as your signature on this agreement.


Please contact me at the information above with any questions.