I ACKNOWLEDGE AND CONFIRM THAT :
- I am of legal age and I am requesting
a consultation with
- This consultation is for educational purposes, is not to
diagnose or treat disease.
- I understand that this consultant is not intended to replace
medical care and I will seek medical treatment from a licensed
health care provider if required.
- I understand that botanical may be contraindicated with
certain health conditions. For this reason, I confirm that
I have had a general physical from a Medical Doctor within
the last 12 months, and have disclosed any conditions diagnosed
on the intake form.
- I understand that botanicals can interact with medication.
For this reason I have disclosed all medications on the intake
- I understand that herbal medicine is not regulated nor approved
by the Federal Drug Administration.
- I understand that no guarantees are made regarding results
from herbal medicine or natural health methods, and that achieving
wellness requires my commitment to my own good health, whether
through diet, exercise or stress relief.
- I am under no obligation to follow any recommendations for
lifestyle changes made by the consultant.
- In consideration of my acceptance as a participant in this
private consultation session, I for myself, heirs, executors,
administrators and assignees, do here by release and discharge
______________ or any of its employees from all claims of
damages, demands, or actions whatsoever in any manner arising
from all growing but out of my participation.
If you are agree, mail us at
email@example.com in following format