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By electing to work with Root Cause Clinic and/or one of the Independently Contracted Practitioner, I hereby acknowledge and agree:

1.    RCC provides a completely non-invasive method for gaining valuable information about your body’s energetic functions. The primary objective of the screening is to disclose patterns of stress and provide feedback that will assist in developing a program to restore each system and meridian to balance. Take note that 30-minute appointments are not to be used to review scans as this would not allow for a smooth and comprehensive approach. 


2.    I understand that Root Cause Clinic is a Bioenergetic Laboratory Testing Service Practitioner and does not provide 1-on-1 private consultations. As an added convenience to the client, Root Cause Clinic has a list of Independently Contracted Practitioners trained in interpreting the "raw data" in order to provide further insight into my energetic health. I understand that Root Cause Clinic is not responsible for the interpretation of results by any Independently Contracted Practitioner.


3.    I understand that the scan/ test does not provide a medical diagnosis and that my testing technician/practitioner may recommend further medical testing. If I suspect I need further medical intervention, I understand I should consult my physician. I give my permission for the testing technician to evaluate my sample. I understand in doing so my testing technician is NOT becoming my primary care physician. I understand that the testing technician will give me information about myself and make recommendations based on the screening. I understand that the testing technician will not pass judgments on prescribed medications, and it is the responsibility of my primary care physician to make any adjustments on prescribed medications. Any decision to follow through with the recommended program is my own decision and I hold the testing technician/practitioner and Root Cause Clinic free of any and all liability for any decisions I choose to make with the information provided.


4.    I understand that I am here to learn about natural health and better lifestyle practices, and I will be offered information about food supplements and herbs as a guide to general health.


5.    I understand that I should continue to see any medical doctors I am currently under the care of, and that any prescribed medications should not be altered without first consulting the physician who recommended it.


6.    I fully understand that those who counsel me are not medical doctors, medical practitioners, licensed nutritionists, or licensed naturopaths. I am not here for any medical diagnostic purposes or treatment procedures.


7.    Information about traditional uses of supplementation that may create a healthy balance in the body may be discussed. This is not intended to be interpreted as a substitute for a licensed physician’s treatment. Nothing said, done, typed, printed or reproduced is intended to diagnose, prescribe, treat, or take the place of a licensed physician.


8.    The intent is to provide educational information for the purpose of assisting you with the lifestyle changes necessary to regain and maintain an environment needed to support a well-balanced lifestyle.


9.    I am not on this visit, or any subsequent visit, acting as an agent for the federal, state, county, local law enforcement, or news media on a mission of entrapment or investigation.


10.    I understand that all information and conversations will be kept confidential but may be recorded for quality assurance and training purposes, and that information concerning myself will not be released to anyone outside of Root Cause Clinic.


11. I understand that the screening will only identify energetic imbalances and does not diagnose any diseases in the body. The Balancing Item refers to the energetic signature needed to restore balance to the body's energy field. Balancing Items are defined differently from medical terms and are not a cure for any disease.



12.    I recognize that the screening is an unorthodox approach to balancing my health. Being of sound mind, I have chosen this screening to assist in balancing my health of my own free will and in the exercise of my constitutional right for the attainment of life, liberty, and the pursuit of happiness.


13.    I understand that my package expires 6 months from the date of purchase and if not used in full, the remaining unused package will be forfeited. No credit will be issued in lieu of the use of the package. No refunds will be issued. 


14.    I understand that the technology Root Cause Clinic uses is not diagnostic, but for the sole purpose of identifying and balancing unhealthy energy patterns.


15.    I also understand that if a balancing energy pattern shows up in the testing procedure the analysis is not saying that this is present in the body but simply that the energetic pattern is needed for bringing the body to homeostasis (balance) so it can better heal itself.


16.    I understand that this does not take the place of advice given by my primary care physician and that if I have any questions regarding the suggested protocol schedule and the interactions of prescribed drugs, I will consult my physician. I will speak to your Primary Care Provider prior to initiating or stopping any supplements or pharmaceuticals.


17.    I also understand that the detox process can create a healing crisis and it is possible I will feel worse before I feel better. This is considered a normal part of the healing process (herx).


18.    I understand that Root Cause Clinic and its techniques have not been evaluated or approved by the FDA.

We reserve the right to refuse service and sales should we deem the relationship unsafe/ unhealthy for either party. We take your privacy seriously and must make you aware that we must report to the proper local authorities should any disclosures be made pertaining to the safety and welfare of any person in danger. I UNDERSTAND THAT THERE WILL BE NO REFUNDS ONCE PAYMENT HAS BEEN PROCESSED.

19.    I understand if I am not satisfied with the results after testing has taken place, I am not entitled to a refund of any kind.


20.    I understand that results cannot be guaranteed. 


21.    I understand that a protocol created by Root Cause Clinic or Independently Contracted Practitioners does not constitute a replacement for medical care and does not guarantee a change in health status. 


22.    I am of sound mind and understand that I am choosing to work with Root Cause Clinic and Independently Contracted Practitioner. 


23.    I may elect to change the protocol recommendations which can also alter the results, as each item chosen was done so with the intent to provide complete support.


24.    Packages are to be used by one individual. Both test kits must be used by the individual whom the package was booked for. 




I hereby acknowledge and agree:


1.     The purpose of nutritional counselling is to improve the overall health, vitality and well-being of the body through nutritional education and the use of natural foods and non-medicinal nutritional supplements. The Practitioner & Root Cause Clinic, do not diagnose diseases, disorders or conditions.


2.     The Practitioner, is not a licensed Dietitian, Naturopathic Doctor or Medical Physician. Should they have the above mentioned licensures, they do not operate under those licensures when doing contracted work for Root Cause Clinic.


3. As part of the Nutritional Counselling Services, I may be asked to provide information concerning my physical habits, medical history, moods, energy levels, likes and dislikes, lifestyle and diet. This information is collected to enable the Practitioner to: (i) assess my knowledge of nutrition, (ii) education me about the benefits of sound nutritional practices and (iii) recommend dietary changes to improve my general health, vitality and overall

well-being. The Practitioner & Root Cause Clinic will hold this information in confidence and will not release or disclose this information to any other person, without my prior consent, except as required by applicable law.


4.     If the Practitioner or Root Cause Clinic, suspects the existence of disease, disorder or condition, I will be informed of this suspicion. However, I acknowledge this is not a diagnosis or conclusion about the state of my health and that I am directed to promptly consult a licensed Physician or Naturopath about any suspected problems.


5.     Should I request the Practitioner, to recommend dietary changes and/or nutritional supplements to enhance my body’s natural ability to resist and/or overcome a known disease, disorder, or condition, it is my responsibility to disclose the nature of the disease, disorder or condition and all other relevant details to the Practitioner. If I have not previously consulted a licensed Physician or Naturopath about this disease, disorder, or condition, I acknowledge that I am directed to promptly do so. I am not to alter or discontinue treatments prescribed by a licensed Naturopath, Physician or other licensed health professional without consulting the individual who prescribed the treatment.


6.     In providing Nutrition Counselling Services to me, the Practitioner, is relying upon the truth, accuracy and completeness of all information I have provided to her. Any recommendations I follow for changes in diet, including the use of nutritional supplements, are entirely my responsibility.


7.     Root Cause Clinic is in no way liable for my health or safety.


8.     In consideration of my participation in the Nutritional Counseling Services, I hereby accept all risk to my health, including injury or death that may result from such participation and I hereby release the Practitioner, on my behalf and on behalf of my personal representatives, estate, heirs, next of kin, and assigns from any and all costs, claims, causes of action and damages arising from any and all illness or injury to my person, including my death, that may result from or occur as a result of my participation in the Nutrition Counselling Services, whether caused by negligence or otherwise.


9.     72 hours is required for cancelling appointments. Appointments cancelled within 72 hours of your appointment time, you will be billed at Clinics discretion.


10.     I understand that any therapies I undertake at Root Cause Clinic are undertaken of my own free will. I accept that the ultimate responsibility for my health care is my own and that Root Cause Clinic is here to support me in this. I understand that my practitioner reserves the right to determine which cases fall outside their scope of practice, in which event an appropriate referral will be recommended. I hereby agree to assume full responsibility for any manner of loss, injury, claim or damage whatsoever, known or unknown, incurred as a result of same and I, my heirs, executors, administrators or assigns for any loss, injury, claim or damage sustained as a result of my attendance and/or participation. I have read the above release and waiver of liability, and fully understand its contents and voluntarily agree to the terms and conditions stated.



I understand that if I purchase a Biophoton Test Kit without consult and then later decide to have the data reviewed by a Practitioner I will be charged the following rate of $165 for a 1-hour review. 


I understand that the Practitioner nor Root Cause Clinic can't provide ongoing support via social media/email/ or any other avenues not listed below and that the proper channels to inquire about support would be by purchasing one of the following: 



$82.50- 30 min appts 

$165.00- 60 minute appointment 


I understand that my card will be saved and charged for any overage of time outside of the purchased time with a Practitioner at a rate of $2.75 per minute (for example, if you purchase a 15-minute appointment, going over by 5 minutes will create an automatic charge of $13.75)


I understand that I can NOT use any coupons/discount codes if I opt into a payment plan. 


I understand that if my payment defaults, then my services will be suspended until payments are satisfied.


Appointment Cancellations. Cancellations without forty-eight (48) hour notice to the Practitioner for any sessions may result in a $35.00 charge for your session which will be automatically deducted from the card on file, as that time has been set aside specifically for you.




I understand that by working with Root Cause Clinic in any capacity with or without monetary exchange, all content including but not limited to forms, videos, concepts, ideas, results, etc is protected content under Copyright laws and any unlawful recording, sharing, distribution without written consent may be prosecuted to the extent the law allows. 

I will not distribute or replicate content as my own. 


I will give all credit to Root Cause Clinic by citing them should I be given permission to share any of the above-mentioned content. 


Root Cause Clinic gives full consent to share short snippets on social media when @rootcauseclinic is being "tagged" or given credit for the content mentioned above. 


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