I acknowledge the Nutritional Profile, Evaluation and Suggested Nutritional Program and any supplemental materials such as vitamins, minerals, enzymes, aromatherapies and herbs are not for the diagnosis, treatment, cure, alleviation, prevention, or care/cure of any “disease” of any kind in any way. I agree I am totally responsible for obtaining qualified medical assistance for any such services or for the care of any “disease” or “pathological” condition. Nevertheless, I reserve myself the right to use the knowledge I gain from the consultation in any legal manner I may choose in the care of my own body. I further declare the sole reason for requesting services from this office is for obtaining a “Suggested Nutritional Program” for the building of my health and wellbeing.
I recognize that analysis is a revolutionary and unorthodox approach to health and that it is based in Jesus Christ. Being of sound mind and with my own free will, I choose this method of building my health and exercise my Constitutional Right for the attainment of life, liberty and the pursuit of happiness.
Consultations are limited to education in matters pertaining to the improvement in the overall health and physical fitness for maintenance of the best possible state of physical, mental and emotional health. These subjects may or may not include examination of urine and/or saliva. Such procedures are not for the diagnosis or treatment of any health condition or “disease”. Any procedures including fasting and/or cleansing are at my own choice.
I am fully aware of the fact that the services being provided to me are spiritually oriented and those who counsel me have been educated in an alternative counseling discipline. I realize my God given rights and Constitutional rights which allow me to seek the best care and education for my own personal needs.
I am aware I am entitled to receive information from my counselor(s) about any method or procedure to be used, fees to be charged and the approximate length of procedure(s), if it can be determined by personal experience, testimonies and suggestions. I understand that if for any reason I am unable to keep a scheduled appointment, a 24-hour notice is to be provided and that failure to provide said notice will result in a no-show fee.
I am free to obtain a second opinion at any time I feel it is necessary.
I understand all I say is to be kept confidential and that information concerning myself can be released to another alternative health practitioner only with my signed consent.
I authorize my wellness counselor(s) to perform any and all health services for me that I have a right to perform for myself and agree to hold the counselor(s) blameless for any and all such acts. I acknowledge and understand that nothing stated by my wellness counselor(s) is in any way, shape or form legal or medical advice. I agree that any matters pertaining to legal advice are to be obtained from an attorney licensed to practice law.
I am not a representative of any branch of a municipal, state, U. S. government, the American Medical Association or the Federal Drug Administration.
I have read and fully understand the above information and do hereby request I be allowed to participate in a health consultation program.