Please review the following Disclosure and Consent Form to be signed at your first appointment.

DISCLOSURE AND CONSENT FORM

I understand that while Jeremiah Loch has advanced clinical education, training, and experience in the field of conventional allopathic and osteopathic medicine that benefits his clinical skills, he is not functioning as an allopathic or conventional medical or osteopathic, physician or as a primary care practitioner of any sort.  The practice he offers is non-medical and focuses on supporting the body's own inherent homeostatic system for healing, balance and repair.  His practice is more accurately and commonly considered within the realm of natural medicine or alternative or complimentary care.  I understand that he is trained in a Biodynamic Osteopathic Approach to bodywork and that he is a licensed and nationally board certified massage and bodywork practitioner that allows for the incorporation of the principles of this approach.  I understand that the use of the title doctor as used here refers to natural medicine, in which he is board certified as a Doctor of Natural Medicine by the American Naturopathic Medical Examination Board, and to his PhD degree in Religion and Health Sciences.  I understand that his treatment philosophy of Healing and his Healing practice is based upon a perspective of Soul-Body integration and upon principles found within a Biodynamic Osteopathic Cranial Approach to Healing.  This approach recognizes the spiritual concept of Grace as a fundamental aspect of Healing and works with the body's natural subtle rhythms and inherent Health. 

By signing the reverse side of this document I acknowledge understanding of the above and I consent to "Hands-on" assessment and treatment that involves contact between my body and the practitioner's body.  I understand contact may include my extremities and areas of my  head, neck and face and areas of my back, chest wall, abdomen, pelvis and sacrum.  I understand that a vibratory device termed a Fulford Percussion Hammer tuned to detected tissue restrictions and rhythms may on occasion be incorporated.  I understand that high and low velocity, so called "cracking" or "popping," techniques are not be incorporated in this approach.

Due to the nature of this type of practice I understand that the practitioner may or may not make notes in the documentation of my sessions.  Such notes will be for the refreshment of memory only regarding certain findings that he may judge could be important for a future visit.  No clinical records are kept in the usual sense of medical records to be used or referred to by other practitioners or insurance companies.   

I understand that I must wear loose fitting clothing and that I may be asked to remove or rearrange some clothing to facilitate assessment and treatment.

I have circled on the diagram below any body areas where I do not feel comfortable receiving physical hands-on or vibratory touch.

I look forward to seeing you and working with

"the Health" within you!