Energetic Healing & Wellness Services
Dr. Gloria Roohr-Hyzer, ND, CBFT
Phone: (608) 524-2605
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    Please Read and Sign Before Continuing

    If you are requesting a Remote-Distant Healing Session you must read and sign the consent form below.

    Please print out the form and Fax it to 1-715-648-5782

    Consent Form - Agreement for Morning Glory Wellness Services:

    Mornin Glory Wellness Center, wellness consultant and distance healing
    services are for bio-feedback and bioreasonace therapy. Other terms used for
    this type of therapy are Vibrational Medicine or Energy Medicine or Energetic
    Medicine. Our main concern in your health is with the correction of energy fields
    and changing your energetic blue-print by balancing the bio-electric frequencies.
     
    I, HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge
    Mornin Glory Wellness Center., and its agents, participants, employees,
    biofeedback practitioners, employees, officers, directors, affiliates, successors,
    members, trustees, managers and assigns, of and from any and ALL claims,
    demands, debts, contracts, expenses, causes of action, lawsuits, damages and
    liabilities, of every kind and nature, whether known or unknown, in law or
    equity, that I ever had or may have, arising from or in any way related to the
    distance healing services or any other modality I receive from Mornin Glory
    Wellness Center, including EPFX-SCIO, bioresonance, and/or any other
    complimentary healing instruments or consultation.
     
    This agreement shall be unlimited as to amount of duration, and it shall be
    binding upon and inure to the benefits of the parties, their successors, assigns
    and personal agents and representatives.
     
    I fully understand that the attending biofeedback practitioner is not a licensed
    medical doctor, rather she is a stress reduction specialist that provide
    information and services for lifestyle changes.
     
    I fully understand the difference between the practice of allopathic medicine,
    nutritional wellness consulting, and biofeedback therapy.
     
    I fully understand that Mornin Glory Wellness Center, advises that I should
    consult my own medical practitioner and medical professional for diagnosis,
    care, treatment or cure to any health condition. Morning Glory Wellness Center,
    and biofeedback practitioners do not diagnose, treat, prescribe or claim to cure
    any disease.
     
    I fully understand that the services provided by Morning Glory Wellness Center
    are not allopathic but are nutritional, behavioral, or biofeedback in nature.
     
    I fully understand that Morning Glory Wellness Center performs her services
    within the parameters of natural health care and wellness system using
    biofeedback and stress reduction therapies.
     
    I fully understand that Morning Glory Wellness Center do not offer allopathic
    drugs, surgery, or chemical stimulants or radiation therapy. I also understand
    that illness is not being diagnosed nor treated and that my wellness and stress
    are being measured.
     
    I have solicited Morning Glory Wellness Center as the attending biofeedback
    practitioner in good faith, exercising my free will and following the dictates of
    my own conscience that allow me to select what I understand is most
    beneficial to my health.
     
    I fully understand that this biofeedback therapy and/or wellness consultation
    does not guarantee any healing outcome that may result from an interacting
    with the biofeedback practitioner. I understand that healing is not bound by
    particular time periods. I am of sound mind and able to make decisions about
    my own health.
     
    I presently seek counsel, advice, opinions, biofeedback or points of view/or
    programs within the scope of the attending biofeedback practitioner of natural
    wellness and stress reduction practice.
     
    I hereby release Mornin Glory Wellness Center, from any and all liability with
    regard to the services of the biofeedback practitioner.
     
    By this WAIVER, I assume any risk, and take full responsibility and waive any
    claims of personal injury, death or damage to personal health.
     
    This WAIVER AND RELEASE contains the entire agreement between the parties,
    and supercedes any prior written or oral agreements between them concerning
    the subject matter of this WAIVER AND RELEASE.
     
    The provisions of this WAIVER AND RELEASE will continue in full force and effect
    even after the termination of the activities conducted by, on the premises of, or
    for the benefits of Morning Glory Wellness Center, whether by agreement, by
    operation of law, or otherwise.
     
    I have read, understand and fully agree to the terms of this WAIVER AND
    RELEASE. I understand and confirm that by signing this WAIVER AND RELEASE I
    have given up considerable future legal rights. I have signed this Agreement
    freely, voluntarily, under no duress or threat of duress, without inducement,
    promise or guarantee being communicated to me. My signature is proof of my
    intention to execute a complete and unconditional WAIVER AND RELEASE of all
    liability to the full extent of the law. I am 18 years of age or older and mentally
    competent to enter into this waiver.
     
    I have read and agree to the procedure set forth to engage in a Quantum Biofeedback Energetic rebalancing Session which had been explained to me by Morning Glory Wellness Center and
    that I authorize and consent to the performance of the foregoing services.

     

    Your Signature________________________________Date____________

     

    Book this Session  -  60 Minute Session-Consultation-Therapy - $80.00

    (Includes phone U.S. phone charges, report and color session charts)

    Book this Session - 90 Minute Session-Consultation-Therapy - $150.00

    (Includes U.S. phone charge, a detailed report, and color session charts via e-mail)

     
     

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    Consent Form



    Telephone Appointments
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    Disclaimer: Information on this site is provided for informational purposes and is not
    meant as a substitute for the advise of your own health care physician or other health care professional. You
    should not use the information contained herein for diagnosing or treating a disease or problem or for prescribing any medications
    If you have a medical problem, we advise you to seek appropriate medical professional. Please consult with a health
    care profession before starting any supplementation, diet, exercise or medicine program.The EPFX-usb system is used as a Biofeedback Multimedia System. It is designed for stress detection and stress reduction. The device does not diagnose anyone. Only a Licensed Medical doctor can diagnose a patient. This system is calibrated to measure the fine and subtle electrical and subspace reactions to a group of biological and medical substances. The sensitivity is set so fine as to pick up the earliest sign of disease and distress. Thus the results might (may) be below the client recognition. No claims are made of the system or results.