The Pretty Hot Mess, LLC Informed Consent and Disclosure Form
The Pretty Hot Mess Wellness Boutique
152 Warren St.
Glens Falls, NY 12801
Informed Consent and Client Disclosure Form
About The Pretty Hot Mess, LLC
The Pretty Hot Mess is a wellness boutique located in Glens Falls, NY. It was founded in 2018 by local resident and former Nurse Practitioner, Angel Isaac. Its purpose is to share the ancient wisdom of how to help maximize your health through the utilization of Essential Oils and other natural supplements. PHM does not offer medical consultations but we will discuss all the customers’ needs on an individual basis. We provide education, information and assistance with ancient remedies and spiritual practices in our retail shop.
I have long held a global belief that the human body possesses the innate ability to heal itself, mind, body and spirit. I also believe that in today’s world of fast paced, high stress lifestyles, sometimes those inherent reparative mechanisms inherent in each of us needs some support. At PHM, I work with ancient remedies, crystals, and spiritual practices to help maximize the health of each individual customer. Natural healers don’t isolate body parts or diseases. We see the interconnections in the human body and work to gently nudge all pieces back into balance. My goal at PHM is to help bring the natural healing mechanisms within each and every one of us back into balance in a way that is gentle and natural by uniting modern science with long-established traditions and ancient healing practices.
Confidentiality, Code of Ethics, and Practice Information
All information discussed with myself or PHM staff is completely confidential and will be treated with the utmost respect and care. Due to HIPPA privacy regulations, information shared with PHM will not be discussed or disclosed with any other person without the written consent of the signed individual. Myself nor my staff are not medical doctors. We do not diagnose, treat, prevent, or cure any diseases. At PHM, we believe that ordinary people, by ordinary means, can have access to healthy living. You can be empowered to maximize your own health with plants, crystals, energy, and spiritual means found in nature. We are here for educational purposes only and to assist you in finding natural alternatives to add to your daily routine. We strongly encourage you to discuss all of your medical needs with a licensed medical provider.
Natural oils and CBD are generally safe. At PHM, I prefer to work with plants and oils that are generally recognized as safe. However, there are some cases where special care and consideration must be taken. It is your responsibility to fully disclose any medical conditions and any medications or supplements currently in use. I also recommend that you inform your doctor of all herbal and nutritional supplements you are taking. In the event of an adverse reaction, immediately discontinue use and call your doctor.
Essential oils and CBD should not be used in pregnancy or lactation without expert advice. If you become pregnant, I recommend you immediately stop using any natural products and call to schedule an appointment with your health care provider.
By signing this Informed Consent and Client Disclosure Form I acknowledge and confirm that:
• I am of legal age and I am requesting education and information from Angel Isaac and or The Pretty Hot Mess staff for myself or my child. I understand that if I am seeking information and education regarding persons under the age of 18, I am the legal guardian or parent of such individual.
• I acknowledge that any information or education I receive is not to diagnose, treat or cure any disease, but for education and support of wellness and is not intended to replace medical care and that I will discuss all information/education I receive at PHM with my health care provider. I understand that botanical and nutritional supplements may be contraindicated with certain health conditions and interact with certain medications. For this reason, I confirm that I have had a general physical from a Licensed Medical Provider within the last 12 months, or have chosen not to, and have disclosed any diagnoses and medications with the PHM staff so that they may have an opportunity to appropriately educate you about possible adverse affects or interactions with any conditions or current prescriptions you are currently taking.
• I understand that it is my constitutional right to decide how I wish to care for my or my child’s health. Angel nor her staff has not suggested that I cease any current medical care or therapies for myself or my child. I have sought Angel and her staff’s advice and I recognize that I am free to act upon her recommendations as I see fit, and, as such, release her and her staff from all responsibility for my actions and any consequences thereof, both now and in the future. I further understand that I am under no obligation to follow any of the recommendations made.
• I understand that herbal, botanical, and plant based supplements are not regulated or approved by the Federal Drug Administration and I will only use them as directed for intended use.
• I understand that no guarantees are made or implied regarding results from The Pretty Hot Mess products or natural health methods, and that achieving wellness requires my commitment to my own good health, working collaboratively with my PCP, through diet, exercise, or lifestyle changes.
• I am here on this and subsequent visits solely on my own behalf and not as an agent of federal, state or local government agencies for purposes of investigation or entrapment.
• I acknowledge that all natural products, including but not limited to oils, salves, CBD are final sale and are not able to be returned or exchanged once they have been opened.
Please Provide Your Legal Name and Age
I acknowledge that I have read and understood this document. I hereby voluntarily consent to obtaining information from The Pretty Hot Mess, LLC within these parameters. I acknowledge that information and education given by PHM staff is not a substitute for regular medical care and that Angel Isaac and any staff at PHM are not licensed medical providers. All information is shared in the spirit of empowering me to better understand and heal myself or my children.
I acknowledge and understand
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