AT3 Self Test Informed Consent and Release Form

AT3 SELF TEST INFORMED CONSENT AND RELEASE FORM

The AT3 System is a form of bio-energetic science. This test is non-invasive and painless. It measures the energy fields within the body. The science of computerized electrodermal testing is based on physics, not chemistry. I understand the AT3 System is not meant to diagnose, treat or cure disease. This self test is not intended to take the place of any conventional medical test or diagnostic procedure. At no time will there be any implied or stated indications to discontinue care under the direction of a licensed physician.

By signing this form, I am voluntarily willing to undergo this self test. I am doing this with full knowledge that I am acting as my own care provider and take responsibility as such. I understand that the testing procedure and services rendered are not licensed by the State of Washington. I also understand that Joyce Tasker is not a licensed healthcare professional and I hold her harmless without exception. I understand that it is my right at anytime to discontinue these services.

I have fully read and understand the above information, my rights and responsibilities and hereby give my CONSENT.

*Note: If you are *not* referred by a doctor, you *must* sign and return this Consent Form. For AT3 Biofeedback Screening send with completed forms with check or money order payable to Dog Patch / Joyce Tasker for $295.00 for complete analysis.

The self test fee includes screening, products, shipping and handling and support. Please enclose initial payment with saliva sample. Fees support a humane society.

• Product refills are an extra charge
• International shipping charged at actual cost
• Non-tincture products additional charge

Pre-paid screenings are available.
3 screenings per individual client $800.00 (savings of $85.00)

Make check payable to: Dog Patch / Joyce Tasker