Jail this bastard!
http://web.archive.org/web/20130117135940if_/http://www.simplyhealingclinic.com/sites/default/files/pdf/Fast_Healing.pdf[*quote*]
NATUROPATII TREATMENT SACKNOWLEDGEMENT AND
AGREEMENT,
Thisagreement (Agreement) is entered into on ............................................., 201.......between Aleksander
Strande, MS.,Ph.D., and the corporation in which Dr. Strande conducts his practice, Fast Healing, Inc. (together
*Fast Healing, Inc. unless otherwise noted) and............................(Patient). The puropse of this Agreement is to
confirm certain understandings and agreements, and confirm certain information provided to Patient by Fast
Healing, Inc.
1. Patient understands that Dr. Strande is a Board Certified Naturopathy by the Board of Examiners of American
Naturopathic Medical Certification & Accreditation Board, Inc. (Committee on Naturopathic Medical Education,
Washington, and District of Colombia. and licensed as a Naturopath by the Department of Health, Washington,
District of Colombia. He is a member of the following organizations: The American Naturopathic Medical
Association, The association of Nutritional Consultants, American Association of Drugless Practitioners,
American Holistic Association and American Herbalists Guild.
2. Patient understands that Dr,Strande is not a licensed physician. He has a Ph. D. Degree in Naturopathy, a MS.
Degree Microbiology, a Diploma of Herbal Medicine, and Diploma of professional Homeopathic Prescribing
and a Postgraduate Diploma in Clinical Nutrition. As a Naturopath , he does not diagnose disease, treat illness or
prescribe medicine. As a Naturopath, he assists in recovery from ill health and in maintaining well-being.
Services provided are predicated on the enhancement and support of the inherent healing capacity of the
individual body by using natural means. The treatment provided by Fast Healing, Inc. is alternative or
complimentary to healing arts services licensed by the States. However, the services provided are not licensed by
state of California.3. It is the patient’s choice to use any exercise or to purchase or use any supplements (i.e. Vitamins nd minerals),
herbs, homeopathic preparations, foods amino acids, and skin creams, discussed with, referred by or sold by Fast
Healing, Inc., or to by any books, videotapes, or related materials that are recommended.
4. Patient will consult his/her primary physician if he/she so chooses or whenever deemed necessary. Patient will
seek the advice of a doctor or specialist if advised by Fast Healing. Inc., or Patient determines to be prudent or
necessary for any reason.
5. Patient acknowledges that no representations or guarantees have been made by Fast Healing, In., to Patient
regarding the success or outcome of a consultation with or recommendations made by Dr. Strande.
6. Patient represents that all information that he/she has provided to Fast Healing,. Inc. is true and accurate and
agrees that if there is a material change in the information provided; Patient will promptly notify Fast Healing,
Inc. of the change.
7. Patient agrees that if 24-hour notice is not given for the cancellation of any appointment consultation. Patient
will be charged and agrees to pay for the full appointment fee.
8. Patient acknowledges and agrees that no refunds will be given for consultation, freight of supplements. liquid
herbs and powdered amino acids as well as open bottles of other supplements.
9. Patient agrees to pay in full for services and supplements at the time of consultation. If Patient uses another
individual's credit card or check for payment, Patient represents that it is done with the permission of the
individual's and Fast Healing, Ins. is not responsible to verify such permission.
10. This Agreement constitutes the entire understanding and final expression of the agreement between the
parties regarding the subject matter of the Agreement and supercedes any and all prior or contemporaneous
communications, all of which all merged into this Agreement. This Agreement shall not be modified, amended,
supplemented or altered, except by an instrument signed by both parties. This Agreement is intended to cover
services provided both before and after the date of this Agreement.
11. All disputes or claims arising out of, or in connection with the treatments or advice provided by or throughFast Healing, Inc. shall be settled under the rules of the American Arbitration Association by one arbitrator
appointed in accordance with the rules. The place for the arbitration shall be San Diego. The parties agree to
submit themselves to the jurisdiction of the AAA in San Diego, California.
12. This Agreement is intended to be valid and enforceable to the fullest extent permitted. If any provision is
held invalid or unenforceable, such judicial findings shall nt affect the validity or enforceability of any
provisions.
TE SIGNATURE BELOW ACKNOWLEDGES THAT THE UNDERSIGNED HAS RECEIVED THE
INFORMATION CONTAINED IN SECTIONS 1 AD 2.
DATED:________________________________ FAST HEALING,INC.
By:______________________________________
Alexander Strande, MS., Ph.D.
DATED:________________________________ PATIENT
By______________________________________
Signature
________________________________________
Print NameFast Healing, Inc.
3017 Clairmont Dr.
San Diego, CA 92117
Name:___________________________________________________________
Address:_________________________________________________________
Home Phone:_____________________________________________________
Cell Phone:______________________________________________________
Credit Card:_____________________________________________________
Exp. Date:____________________
I authorize Fast Healing, Inc., to use this credit card number. I understand that
payment for services are paid in full at the time services are rendered. I
understand that all sales are final.
Signature:_____________________________________________
Date:_________________________________________________Fast Healing, Inc.
3017 Clairemont Dr., San Diego, CA 92117
Ph:619.607.4211
www.simplyhealingclinic.comCLINET HISTORY
Home Telephone ______________________________
Cell Telephone:_______________________________
Work Telephone:_______________________________
Name:_____________________________________________________________________
Hm. Address:______________________________________________________________
Age/DOB:_____________________ Occupation:______________ No.Children:_______
Main Complaint/Reason for visit:______________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Other Complaints and Findings:_______________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Previous and Current Medications, Supplements and Rx:__________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
History of Previous Illness:____________________________________________________
Childhood:_________________________________________________________________
Adult:_____________________________________________________________________
Mother:____________________________________________________________________
Father:_____________________________________________________________________Diet: ______________________________________________________________________________________
Breakfast:
__________________________________________________________________________________________
Lunch:
__________________________________________________________________________________________
Dinner:
__________________________________________________________________________________________
Digestion:_______________________________ Upper:____________________ Lower___________________
Sleep:_____________________________________________________________________________________
__________________________________________________________________________________________
Energy:____________________________________________________________________________________
Adrenals:
Flushes:
Night Sweats:
Dry Mouth:
Female____________________________________________________________________________________
PMT:______________________________________________________________________________
Periods:_____________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Physical:___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
BP: _______________________________________________________________________________________
IRIS:______________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Tongue:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________Please Circle One
Do you find difficult to sustain concentration or forget things easily? Often Sometimes Never
Do you get weepy, depressed and find it hard to motivate yourself? Often Sometimes Never
Do you get anxious, panicky or shaky inside? Often Sometimes Never
Do you become impatient, irritable or aggressive too easily? Often Sometimes Never
Do you crave sugar or sugary products? Often Sometimes Never
Do you sign and yawn a lot? Often Sometimes Never
Do you suffer sharp shooting pains in the body? Often Sometimes Never
Do you experience twitching od the face or eye muscle? Often Sometimes Never
Do you experience any heart palpitations? Often Sometimes Never
Do you wake up feeling tired? Often Sometimes Never
Do you get stiff or painful joints? Often Sometimes Never
Do you suffer from a sexually transmitted disease? Yes No
Does your head feel fuzzy, as if it’s full of cotton? Yes No
Do you suffer from headaches? Often Sometimes Never
Do you have excessive hair loss or split ends? Often Sometimes Never
Are your fingernails soft or do they flake or crack? Often Sometimes Never
Do you catch colds or infections easily? Often Sometimes Never
Do you suffer from yeast infections or thrush? Often Sometimes Never
Do you suffer from blocked sinuses or sinus headaches? Often Sometimes Never
Do you have any post-nasal throat or chest mucus that is green or yellow? in
color?
Do you have respiratory mucus that is white in color? Often Sometimes Never
Does the skin or your lips, hands or feet crack? Often Sometimes Never
Do rich food disagree with you? Often Sometimes Never
Do you feel a tight band around your chest, head, throat or abdomen? Often Sometimes Never
Do you suffer from hernia, hemorrhoids or varicose veins?
Often Sometimes Never
Yes No
Do you suffer from cystitis or urethritis? Often Sometimes Never
Do you easily or do cuts take a long time to heal? Often Sometimes Never
Your signature_____________________________________________________Date___________________
Please print name__________________________________________________________________________
[*/quote*]