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Consent

I, the undersigned, do hereby give consent to Marco Becker Biokineticist to disclose information regarding my diagnosis (ICD 10 Coding), medical condition, prognosis, treatment compliance, and treatment program to the following people/institutions for the purpose of reimbursement or settlement of his / her account, and or for referral and reporting purposes:

By ticking the boxes below you do give consent to sharing information with and requesting information from *:

I acknowledge and agree to abide by the policies and procedures set forth by Marco Becker Biokineticist, which encompass the release of information, biokinetic treatment, financial obligations, consultation protocols, late cancellation policies, and the indemnity waiver, as detailed in our Consent Policy & Procedures document. I declare that the release of information, treatment, and billing procedures of this practice have been discussed with me, and I understand the conditions and implications thereof. I confirm that this consent was not made under duress. If the consultation is for an individual under the age of 12 years old, I accept full responsibility for the individual and consent on their behalf to participate in the consultation.