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Idaho Natural Health Care Services Disclosure

City, State, Zip      
Phone (home)       Alternate phone      
E-mail Address      

 I, the undersigned, understand that Dr. Denice Moffat at 1069 Elk Meadow Lane, Deary, ID 83823 (208) 877-1222, is providing the natural health care services defined as Alternative Healing Techniques and Integrative Healing Techniques on humans and animals, holistic veterinary services, naturopathy, and/or intuitive readings. 

Dr. Moffat has been educated with a BS in Animal Science (Washington State University, Pullman WA), Masters in Biology (Eastern Washington University, Cheney WA), Doctorate of Veterinary Medicine (Washington State University, Pullman WA), Naturopathic degree through the Clayton School of Natural Healing (Alabama), Contact Reflex Analysis certified (Dr. Dick Versendahl), Teaching Karuna Reiki Master (Usui Reiki linage), Neuro Emotional Technique (Dr. Scott Walker California), Advanced Emergency Medical Technician Training (Orofino, ID), CranioSacral Therapy classes (Upledger Institute) and has taken an Ener-Chi and Creative Emotional Wizardry Courses with Dr. Randy Robirds (Las Vegas, NV). 

I understand that Dr. Moffat is not a M.D. (medical physician), D.O. (doctor of osteopathy), and she cannot (for humans) prescribe medications, perform surgery, or deliver babies. 

Dated this                         day of                                                                                                       , 20     .



Please return original form filled out, with your signature, and a photo of yourself and/or pet if we are making recommendations for it/them as well to Dr. Moffat with your payment. Thank you.
Cash Enclosed Check Enclosed  
Visa/ MasterCard Number       Exp      /     
3 digit security code       Address bill comes to if different from above:
City, State, Zip      


Form updated 1/21/11