Intake Forms

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Dr. Hernandez Client Intake Form

* Indicates required field

Scheduled Appointment Date and Time *

Phone Number *

Name *

First

Last

Email *

Wellness Goals and Appointment Concerns *

Weight, Height, Blood Type, pH, (AC/AK) *

Alcohol, Tabacco, Cannabis, Entheogenic Plants? *

Past Surgeries? Allergies? Date and or type *

Do you have a good appetite and good eating habits? *

Do you exercise often? If so, how many times a week? *

Do you eat organic foods? Farmshare or grow your own? *

How would you describe your diet? Or are you on a specific diet? *

What are your sources of protein? *

Do you crave certain foods? Bread, Pasta, Dairy, Meat, Fried Foods, Chocolate *

Do you like or crave particular food flavors? Sweet, Salty, Spicy, Bitter, Sour, Bland, Astringent *

Prescribed medications you are currently taking. *

Herb, Suppplement or Nutritional Routine? *

Past Medical History *

Please be aware that there is a high demand for sessions, we ask that you honor our time as well as yours and adhere by the following guidelines. All cancellations require 48 hour notice prior to your scheduled appointment. Which can be done easily on the online square appointment sceduler. If we do not receive 48 hour notice then your appointment will be considered missed.

All clients will be required to pay the full appointment amount for missed appointments. This fee will depend on which type of appointment you are schedule for. You will not be allowed to reschedule until this missed appointment fee is paid. Emergency situations will be considered on case by case basis. I understand and will abide by the cancellation policy.

Signature *

I understand that:

The Quantum Alignment Therapy work I receive is provided for the basic purpose of education and self awareness. I further understand that Dr. Hernandez is not performing, nor is qualified to perform physical adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the course of the session given should be constructed as such. Together we will be working with Quantum Alignment Therapy to help uncover the root cause of the issue for awareness and healing. Using the right under ARTICLE 4. Application of Chapter [3640 - 3645]
I and or my representatives agree to full release Dr. Pepper Hernandez from and against any and all claims or liability of whatsoever kind of nature arising out of or in connection with my education & discussion session.
In no way is this type of work to be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a licensed physician, licensed chiropractor, licensed acupuncturist or other qualified medical specialist for any mental or physical ailment if needed.
The relationship between the client and the practitioner is a confidential one. All of the information provided to the practitioner is to be kept confidential. I understand to share information I will need to sign a health release form with the office and it should be kept on file.
I have the right to request and require that any conversation, non invasive body exam, technique be modified, changed, stopped, or simply not preformed. As well as informing Dr. Hernandez at any time during the session if the anything needs to be adjusted to my level of comfort.
I affirm that I have stated all my known health conditions and answered all questions honestly. I agree to keep Dr. Hernandez updated as to any changes in my health profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
I understand fully that all suggestions given in the consultation or in the session should be researched before taken as part of a daily practice. I do not under any circumstance hold Pepper Hernandez or DrPepperHernadnez.com for my health, wellness or satisfaction of a session. I understand that this is a place of education and any information is to be used as such.

Signature *

SECTION 2053.5 is added to the Business and Professions Code, to read: 2053.5
Hernandez will not be doing or is permitted to do any of the following:
(1) Conducts surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
(2) Administers or prescribes x-ray radiation to another person.
(3) Prescribes or administers legend drugs or controlled substances to another person.
(4) Recommends the discontinuance of legend drugs or controlled substances prescribed by an appropriately licensed practitioner.
(5) Willfully diagnoses and treats a physical or mental condition of any person under circumstances or conditions that cause or create risk of great bodily harm, serious physical or mental illness, or death.
(6) Sets fractures.
(7) Treats lacerations or abrasions through electrotherapy.
(8) Holds out, states, indicates, advertises, or implies to a client or prospective client that he or she is a physician, a surgeon, or a physician and surgeon.

SECTION 2053.6 is added to the Business and Professions Code, to read: 2053.6.
(a) A person who provides services pursuant to Section 2053.5 that are not unlawful under Section 2051, 2052, or 2053 shall, prior to providing those services, do the following:
(1) Disclose to the client in a written statement using plain language the following information:
(A) That he or she is not a licensed physician.
(B) That the treatment is alternative or complementary to healing arts services licensed by the state.
(C) That the services to be provided are not licensed by the state.
(D) The nature of the services to be provided: Education and Information only.
(E) The theory of treatment upon which the services are based.
(F) His or her educational, training, experience, and other qualifications regarding the services to be provided can be found on her website and will be provided if necessary.
(2) Obtain a written acknowledgement from the client stating that he or she has been provided with the information described in paragraph, please sign below acknowledging this is true. (1). The client shall be provided with a copy of the written acknowledgement, which shall be maintained by the person providing the service for three years.
(b) The information required by subdivision (a) shall be provided in a language that the client understands.
(c) Nothing in this section or in Section 2053.5 shall be construed to do the following:
(1) Affect the scope of practice of licensed physicians and surgeons.
(2) Limit the right of any person to seek relief for negligence or any other civil remedy against a person providing services subject to the requirements of this section Client Signature

ARTICLE 4. Application of Chapter [3640 - 3645] ( Article 4 added by Stats. 2003, Ch. 485, Sec. 5. )3644.
This chapter does not prevent or restrict the practice, services, or activities of any of the following:
(a) A person licensed, certified, or otherwise recognized in this state by any other law or regulation if that person is engaged in the profession or occupation for which he or she is licensed, certified, or otherwise recognized.
(b) A person employed by the federal government in the practice of naturopathic medicine while the person is engaged in the performance of duties prescribed by laws and regulations of the United States. (c) A person rendering aid to a family member or in an emergency, if no fee or other consideration for the service is charged, received, expected, or contemplated.
(d) (1) A person who makes recommendations regarding or is engaged in the sale of food, extracts of food, nutraceuticals, vitamins, amino acids, minerals, enzymes, botanicals and their extracts, botanical medicines, homeopathic medicines, dietary supplements, and nonprescription drugs or other products of nature, the sale of which is not otherwise prohibited under state or federal law.
(2) An unlicensed person described in this subdivision may represent that he or she “practices naturopathy” if he or she complies with Section 2053.6. However, an unlicensed person may not use the title “naturopathic doctor” unless he or she has been issued a license by the committee
(e) A person engaged in good faith in the practice of the religious tenets of any church or religious belief without using prescription drugs.
(f) A person acting in good faith for religious reasons as a matter of conscience or based on a personal belief, while obtaining or providing information regarding health care and the use of any product described in subdivision (d).
(g) A person who provides the following recommendations regarding the human body and its function.
(1) Nonprescription products.
(2) Natural elements such as air, heat, water, and light.
(3) Class I or class II nonprescription, approved medical devices, as defined in Section 360c of Title 21 of the United States Code.
(4) Vitamins, minerals, herbs, homeopathy, natural food products and their extracts, and nutritional supplements.
(h) A person who is licensed in another state, territory, or the District of Columbia to practice naturopathic medicine if the person is incidentally called into this state for consultation with a naturopathic doctor.
(i) A student enrolled in an approved naturopathic medical program whose services are performed pursuant to a course of instruction under the supervision of a naturopathic doctor.

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