DISCLAIMER FORM

Please complete all information for case history and/or file update:

EVENTHOUGH WE ARE EXPERIENCING SUCCESSFUL  RESULTS AND POSITIVE TESTIMONIALS WITH THIS ANCIENT 
HOLISTIC TREATMENT, WE ARE PLEASED TO INFORM YOU OF THE FOLLOWING FACTS:

Ear Coning/Candling is NOT a MEDICAL treatment or cure and no claim is being made as such. It is primarily an ancient holistic remedy used in the improvement of hearing, minor ear maladies and balance disorders pertaining to the OUTER EAR CANAL ONLY. 

It is known as an acupressure alternative to convention medicine. Those participating in this remedy must assume full responsibility for its use; may not hold the ear conologist or the manufacturer of ear cones liable for any such claim, expense or effect resulting from its use. It has proven to be a safe, effective, relaxing treatment for people of all ages beginning as early as 3 years old. 

Your professional Ear Conist  was trained under the qualified supervision of Penny Rich, Founder of the Institute of Certified Ear Candler's in 2000 through 2003 when I.C.E.C. was registered with the State of California Bureau for Private and Postsecondary Vocational Education. It is now a local and nationwide treatment service center.

This is my _________ treatment.

Client's Name: ____________________________________________________________ 

Phone: (        ) ______-___________                        Cell: (        ) ______-______________

Address: ___________________________________________________________

e-mail address if available: __________________________________________________

City/State:________________________                     Zip: ______________

E-mail address (If any): ______________________________________________________

Presenting Problem: __________________________________________________________________________

I have read the above statement and choose to proceed with treatment. Initials: (           )

Signature: _______________________________________________________________

Brief Results AFTER treatment:_____________________________________________

___________________________________________________________________________________

 Note: Contrary to recent negative media exposure and comments, NO hot wax ever drips into the outer ear; nor is it "dangerous" unless treatment is given by an untrained layman as demonstrated on Eye-Witness News on 02/24/2010. We have had 25 years without incident and have treated children as young as 12 months old. The treatment is safe, effective and relaxing; without pain or "heat melting wax inside the ear". The medical profession does not believe in this alternative medicine and tends to defame its reputation and the benefits it offers.