Kim Jandro - Home Life Coach, Emotional/Body Code Practitioner Services Wellness Coaching Integrative Wellness Coaching Form Scheduling Wellness FormsEvents Let’s Talk New Years ResolutionNatural WellnessAboutBlogsContact Services CONSENT FOR PURPOSES OF COACHING AND PAYMENT CONSENT FOR PURPOSES OF COACHING AND PAYMENT(Required) CONSENT FOR PURPOSES OF COACHING AND PAYMENT(Required)I CONSENT to the use of my health information by Kim Jandro, wellness coach, for the purpose of wellness coaching to help improve health and obtaining payment for my coaching bills. I UNDERSTAND I have the right to review Kim Jandro’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes my rights and the duties of Kim Moore with respect to my healthcare information. Kim Jandro, Wellness Coach, reserves the right to change the Notice of Privacy Practices and I have the right to revoke this consent at any time in writing. Signature of Patient or Personal Representative(Required) Name Name of Patient or Personal Representative(Required) Name Subscribe to my Newsletter Email Address * /* real people should not fill this in and expect good things - do not remove this or risk form bot signups */ Kim Jandro Emotion & Body Code Practitioner Contact Me
