1. I am the parent or legal representative of a minor child (named above ) or person for whom I am seeking treatment with Sima Ash and her staff. I agree to the use of video, Skype, the internet, telephone and other technologies to facilitate evaluation and consultations.

2. I desire to have further investigation into the possible biological and/medical problems which either coexist with and/or contribute to his/her problems.

3. I agree to the use of blood, urine and/or fecal specimens for study by various laboratories selected by Sima Ash in consultation with me.

4. I recognize Sima Ash is not a contracted provider for any insurance company and does not file or submit to any insurance company. I understand that I am responsible for payment for all services, and that payment is due when services are rendered. I have had an opportunity to review the fee(s) prior to consultation and/or procedures.

5. I understand that I am responsible for filing my own insurance claims, and that my insurance company may not provide coverage for consultations, diagnostic testing, and/or other procedures or treatments.

6. I understand that no promise or guarantee of outcome or offer of cure or improvement is made by any process, procedure or medical treatment offered by Sima Ash. I recognize that medications or supplements may be used for other than FDA approved indications and that this is not uncommon in the treatment of children.

7. I agree to let Sima Ash consult with or share the data concerning my child with other physicians, professors, and any other affiliation that she deems relevant.

If patient is less than 18 years of age, or can’t legally sign for himself/herself, his/her parent’s or legal guardian’s signature is required.