Quantum Connections
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    Client Intake Form


    CLIENT HISTORY AND INFORMATION


    Informed Consent Agreement

    This consent is in compliance with 2013 Colorado Senate Bill 13-215. As a Complimentary and Alternative Health Care Practitioner, I am not licensed, certified or registered by the state of Colorado as a health care professional. Colorado does not license Quantum Connections llc or any services provided by Quantum Connections llc and Leslie Schroer.
    I am not a licensed medical physician and do not diagnose, treat or prescribe remedies for the treatment of disease. The services I perform, whether in person, by mail or by phone, are at all times restricted to complementary and alternative wellness services intended for the maintenance of the best possible state of well-being.
    I am prohibited from; performing surgery or any invasive procedure; administering or prescribing x-ray radiation; prescribing prescription drugs; using general or spinal anesthetics; administering ionizing radioactive substances; using a laser device that punctures the skin; performing enemas/colonics unless board certified; practicing midwifery; practicing psychotherapy; performing spinal manipulation; practicing optometry; directly administering medical protocols to a pregnant woman or a person who has cancer; practicing dentistry; setting fractures; practicing massage therapy; and providing a conventional disease diagnosis or recommending the discontinuation of a course of care recommended by a health care professional. I am also prohibited from treating children less than two years of age. In order to treat a child who is between 2-8 years of age, I must have a written, signed consent of the child’s parent or legal guardian.
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105 S Mesa Ave, Montrose, CO 81401
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