Please read carefully before submitting:

I, Gloria Gilbère, am neither a medical physician nor a psychologist, and do not hold myself out as one. I am trained as a traditional naturopath*, earned a Ph.D. in natural health, and am trained as a classical and clinical homeopath. As a client, you will be informed of the natural approaches necessary for a lifestyle of healthy living**. The recommendations given are not a substitute for conventional medical treatment; they are natural, non-drug protocols. I do not diagnose, treat or cure, but rather work within holistic, integrative natural protocols to achieve health. It is my goal to assist you in dealing with the underlying causes of your condition, not merely the effects – accomplishing a natural overall approach to your health and quality of life. For any medical problem, it is important that you disclose to my office the name of your physician, any allergies, and any medications you are taking, or have taken within the past 90 days.

At this time, most insurance companies do not pay for nutritional, environmental or wellness healthcare consulting. Please SAVE ALL YOUR RECEIPTS, we do not bill or deal with insurance companies or year end summaries. It is your responsibility to submit or deal with your insurance carrier if your policy covers nutritional and wellness services. Payment is due at time of service, no exceptions – we accept Visa and Master Card.

If we should have to use legal or collection means to collect on your account, you agree that you will be responsible for all charges/fees incurred by us. A finance charge of 2.5 percent per month will be added to all balances beyond 15 days.

Client’s Name:  E-mail:   Date:

If client is minor, parent/guardian must acknowledge below:

Name of Minor:  Age:

Name of Parent/Guardian:  Date:

*Traditional Naturopathy recognizes the healing power of nature, incorporating diet, exercise, pure water, rest, sunlight and fresh air. A doctorate degree from Clayton College of Natural Health prepares each graduate to educate and empower the public to actively choose healthy lifestyle habits. As such, an N.D. who practices traditional naturopathy does not diagnose, treat illness, or prescribe drugs. The traditional naturopath focuses the client's attention on attaining, fine-tuning and maximizing his or her own homeostasis, or internal balance. This holistic approach incorporates health promotion by giving equal consideration to body, mind and spirit. It is a proactive model rather than a reactive (allopathic) model of health care.

**The holistic nutrition consultant and doctor of natural health programs is that of an educator rather than a diagnostician. Clayton College's Ph.D. in Natural Health prepares each practitioner with a solid foundation in what, when and why humans choose to ingest or withhold substances from the physical body. Nutritional fuels include vitamin, mineral and herbal supplements as well as organic "living foods" and pure water. The practitioner's teachings include detoxification methods to eliminate harmful build-ups, nutritional education regarding each individual's optimal supplement program, and sharing the knowledge of healthy, organic foods as fuel versus unhealthy synthetic compounds and toxins.

(rev. 11-05)

Click the button below to print this form, as you need to mail us a signed copy.
You should also print this as a backup and for your own personal records.