BodyTalk Consent Form
Thank you for registering for your BodyTalk Session with Dr. John Veltheim. Before you proceed, please review and sign this form regarding confidentiality practices.
Your involvement with the International BodyTalk Association (IBA) and Dr. John Veltheim is confidential. The IBA and Dr. John Veltheim will not disclose any information about your session to anyone unless you give us written permission to do so. However, there are three confidentiality limitations required by law. These include:
If we suspect that a situation involves child or elder abuse, we are required to report it to the proper authorities.
If we feel that you are a danger to yourself or others, we must take appropriate actions to protect persons from harm.
If a court orders us to present records, we are obligated to comply.
In addition, Dr. John Veltheim will disclose clinical information to the IBA as needed for coordination of services, quality assurance and/or payment, via mail, fax, or electronically. The IBA uses third party providers for booking your appointment and payment processing, both of which are compliant to the highest security standards in protecting your information. Unfortunately, no data transmission over the Internet can be guaranteed 100% secure. Accordingly, despite our best efforts to protect your personal information, IBA cannot completely ensure or warrant the security of any information transmitted for our online products or services. You transmit all such information at your own risk. Once receiving your information, we will make every effort to ensure its security on our systems.
As these BodyTalk sessions are done remotely, you will be solely responsible for confidentiality and privacy at your location. The session will not stop if another person is in your surroundings. Please ensure you take your own measures to maintain confidentiality in your environment. The IBA will be taking measures in clinic to maintain confidentiality and ensure your privacy.
The IBA Policies and Procedures document outlines the guidelines and procedures for complaints if you feel any of your confidential information has been disclosed without your permission.
By signing this document, you affirm that you understand and agree to the privacy and confidentiality terms.
By signing this document, you also affirm that you understand that the session provided by Dr. John Veltheim, BodyTalk System Founder, Instructor and Advanced Certified BodyTalk Practitioner, is intended to enhance relaxation and increase communication within areas of the body. You also understand that the BodyTalk System is not a substitute for medical treatment or medications. You are aware that Dr. John Veltheim does not diagnose illness or disease nor prescribe medications.
You understand that participation in any session is always voluntary and that you may choose to end your participation at any time.
You understand that information exchanged during any session is educational in nature and is to be used at your own discretion.
You understand that by providing this informed consent you are assuming full responsibility for the session and hold harmless the IBA, BodyTalk Practitioner, health clinic, and facility/location where the session is provided.
Payment is due upon booking your session. Since time has been especially reserved for you, please understand that a 24-hour cancellation notice is expected. Missed appointments will be charged, as will appointments canceled or rescheduled with less than 24 hours’ notice. Dr. Veltheim reserves the right to adjust session pricing in the future.
If you have any questions about these matters, or anything else related to your participation, we encourage you to discuss these promptly with Dr. John Veltheim or by emailing firstname.lastname@example.org.
Consent for Session:
By clicking below, you acknowledge that you have read and understand this document and agree to its terms and wish to proceed with a BodyTalk session with Dr. John Veltheim.