If you are having an emergency, please contact your local hospital and/or Primary Healthcare Provider.
Any information received by your Holistic Health Practitioner is not meant to disregard that of your Primary Healthcare Provider. If you are pregnant or nursing, consult your practitioner/midwife before consulting other services. Holistic well-being is a lifelong journey that involves practice and is not free from adverse affects. I am a Holistic Hirudotherapy Practitioner and Holistic Patient Educator and not a licensed medical physician, dietitian or naturopathic doctor, and therefore do not prevent, diagnose, or claim to cure physical and mental diseases, disorders, and injuries. I am not qualified, nor do I intend to advise against the use of traditional medicine. Rather, I hope to educate clients about medical leeches application and positive affect of saliva of medical leeches. Your Holistic Health Plan is meant for education purposes only, and it remains your decision to pursue any information indicated in your plan.
Enter printed Name of
______________________________ / ___________________________ / ________________________
Client Parent Guardian
I, Tamara Alabastro, also known as Tamara Kazbekova founder of Panacea Holistic Center,Inc. from here and now Tamara Alabastro, am a Hirudotherapy Practitioner and Holistic Patient Educator. I am not a licensed physician, nor are holistic clinical nutritionist and holistic patient education services licensed by the state. 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, keep a copy for yourself, and that I keep the one you give me for at least three years. Please complete, sign, and email both pages of this document to [email protected] My method of service in “holistic clinical hirudotherapy and holistic health education” is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services, subject to requirements and restrictions that are described fully on pages 2-3. The idea behind “holistic hirudotherapy and holistic health education” is as follows:
Holistic clinical hirudotherapy is the practice of attachment of medical leeches to particular points of the body correcting imbalances that cause disease and boosting the immune system by providing the body with optimal amounts of substances which are natural to the body.
Holistic Patient Education is an "alternative“ or "complementary" educational approach to health and wellness which focuses on achieving the appropriate balance required for optimal health in the areas of: lifestyle (diet & nutrition, physical fitness, etc.), mental well-being (stress reduction, healthy relationships, etc.), and spirituality (religious beliefs, personal philosophies, character development). The person is educated to view the self as one or a "whole being," hence the name.
As a holistic hirudotherapy practitioner, and holistic patient education, I will provide you with personal consultations and/or sessions that are educational in nature. They will be based on your personal needs and unique profile. I may ask you to read an article or book, inform you about certain vitamins, minerals, herbs, or other supplements, and teach you about how certain changes to your lifestyle or outlook may improve your health and wellness.
My training and education is described below:
I have a certification of hirudotherapy practitioner from the Russian Hirudotherapy Alternative Medicine Courses. I also have a Master Degree in Psychology from North Osetia State University of Russia.
If you ever have any concerns about the nature of your self- help education, please feel free to discuss them with me. State law requires that I recommend that you inform your medical doctor that you are receiving “holistic patient education and holistic clinical hirudotherapy services”. Please remember that doctors, nutritionists, herbalists, and other medical professionals and health practitioners hold widely varying views. I intend to offer health information to help you cooperate with a competent medical doctor (MD) in your mutual quest for health. In the event you use this information without your medical doctor’s (MD’s) approval, you prescribe for yourself – then Tamara Alabastro and Panacea Holistic Center,Inc., assumes no responsibility.
Patient Disclosure for California Senate Bill SB-577 Compliance
Acknowledgement and Consent to Receive Services:
I have read and understand the above disclosure about the holistic clinical hirudotherapy, and holistic health education offered by Tamara Alabastro and Panacea Holistic Center,Inc., and Tamara Alabastro's training and education. I have discussed with Tamara Alabastro the nature of the services to be provided. I understand that Tamara Alabastro is not a licensed physician and that Tamara Alabastro's and Panacea Holistic Center, Inc. services are not licensed by the state. 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 Tamara Alabastro and Panacea Holistic Center, Inc., and agree to be personally responsible for the fees of Tamara Alabastro in connection with the services provided to me.
Indicate capacity to sign if other than client:
(Parent or Guardian)