California Health and Freedom Act

Disclosure Regarding California Senate Bill SB 577

Classical homeopathy is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of the California Business and Professionals Code, I, Dennis Corby, can offer you these services subject to the requirements and restrictions in Attachment A. If you have any concerns about the nature of your treatment, please feel free to discus them with me.

I recommend that you inform your medical doctor that you are under alternative care.

Dennis Corby is, a Certified B.E.S.T. Elite Master Practioner, Certified in NLP, Certified in Time-Line Therapy, Certified in Hypnosis, Certified to teach the Dr. Phil Life Strategies and Ultimate Weight Solution, Certified Postural Alignment Specialist in the Egoscue Method, Graduate of the Anthony Robbins Coaches Academy 2001, participant in the Anthony Robbins Mastery University which includes Life Master, Wealth Mastery, and Date With Destiny. Dennis is a regular volunteer for the Anthony Robbins event, Date With Destiny and Unleash the Power Within, and takes particular pride in being part of the fire team.

Dennis believes in living what he teaches and recently participated in Morter Health Systems Health Weekend and Intentional Living with Dr. Sue Morter.

Acknowledgement and Consent to Receive Services

In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. I provide a copy for signature at our first visit. I will keep the original in my records for three (3) years.

• I have read and understand the above guidelines and disclosure about the treatments and techniques offered by Dennis Corby as well as his training and education.
• I have discussed with Dennis the nature of the services to be provided.
• I understand that Dennis is not a licensed physician, and that alternative services are not licensed by the state of California.
• I understand it is my responsibility to maintain a relationship for myself / my child with a medical doctor.
• I have consented to use the services offered by Dennis, and agree to be personally responsible for his fees in connection with the services provided.

Print Name of patient:_______________________________

Print Name of person signing, if different: ________________________

Circle one:        Self         Parent         Conservator            Guardian

Signature: ______________________________________________

Date: _________________________________________________

Attachement A: California State Senate Bill SB 577

California Senate Bill SB 577, which was signed by the govenor in September 2002, has profound implications for the practice of alternative forms of healthcare in California. SB 577 enables alternative and complementary health care practitioners (including, but not limited to, homeopaths) to provide and advertise legally. They must also, however, comply with certain requirements specified within the bill

What does Senate Bill SB 577 mean for you, the patient?

SB 577 provides you with access to alternative and complementary health care practitioners. You must be given information about the nature of treatment and practitioner's qualifications. Feel free to ask a practitioner any question you might have about your treatment. Check to see if your practitioner has been certified by a professional membership society. In addition, tell your doctor about any alternative treatment you are pursuing. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health care needs.

SB 577 helps to protect you

SB 577 requires unlicensed alternative health care practitioners to follow certain guidelines and restrictions.

Here are the things that unlicensed alternative practitioners are not allowed to do:

• Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
• Use X-Ray radiation
• Prescribe prescription drugs, or recommend that you discontinue drugs that were prescribed by a licensed physician.
• Set fractures.
• Treat wounds with electrotherapy.
• Put you at risk of great bodily harm, serious physical or mental illness, or death.
• Imply in any way that they are licensed physisians.

In addition, an unlicensed alternative practitioner must do the following things.

• Provide you with a statement, written in plain language that includes the following information:
  • That he or she is not a licensed physician and that his or her services are not licensed by the state;
  • A brief clear description of the kind of services he or she provides and the reasoning behind it; and,
  • A description of his or her education, training and experience.
• Ask you to sign an acknowledgment that you received the above written statement, and provide you with a copy of it. They must keep a copy of your signed acknowledgment for three years.