Form – Informed Consent By signing this form, I the undersigned patient, acknowledge that I am choosing to work with Dr. Jennifer L. Sims DC, licensed Chiropractic Physician. Dr. Jennifer L. Sims is not a primary care physician. Blue Sky Health and Wellness encourages you to have a primary care physician. Dr. Sims specializes in working with pediatrics and women’s health from an alternative, holistic perspective. Her services do not take the place of your primary care physician.Please complete the information below to acknowledge.Name of the Signatory(Required) I, hereby acknowledge that I have read and understand the policies of Blue Sky Health and Wellness. Phone(Required)Email(Required) I understand that I am to have a primary care physician, and the primary care physician’s contact information is listed below:*(Required)Please provide Name of Physician, Office Email, Office Street Address and Office Phone # here.Voluntary Consent: My consent to use alternative care therapies, in the forms of nutritional counseling, testing or other complimentary modalities, is given voluntarily without coercion and may be withdrawn. I am competent and able to understand the nature of the agreement that I am choosing.*(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.No Guarantees: I am aware that everyone is an individual and will respond differently to treatments and that there are no guarantees to the outcomes of testing and treatment recommendations that I receive from Blue Sky Health and Wellness.*(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.I HAVE CAREFULLY READ THIS FORM AND ACKNOWLEDGE THAT I UNDERSTAND IT. NO REPRESENTATIONS, STATEMENTS OR INDUCEMENTS, ORAL OR WRITTEN, APART FROM THE FOREGOING WRITTEN STATEMENT HAVE BEEN MADE.*(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.Date Signed(Required) MM slash DD slash YYYY Please do not submit any Protected Health Information (PHI).CAPTCHANameThis field is for validation purposes and should be left unchanged. Please do not submit any Protected Health Information (PHI).