Please sign and bring email to office on 1st appointment.

Memorandum

Date:_________________2017

To whom it may concern:

To establish and clarify my purpose in coming to you for a consultation, I want to clearly state that my interest is in learning a good path to follow and a good nutritional program. I want to change my present habits and establish new habits and a new way of living to build good health. I understand it is my personal decision to follow your nutritional program or not to follow it.

I thoroughly understand that this program does not replace any additional professional counseling with any doctor I may wish to consult. Your analysis and nutritional counseling is an adjunctive analysis which can be coordinated with any advice, treatments or prescriptions recommended by my regular physician. This program is not intended to be in any conflict whatsoever with any recommendations or treatments by other doctors or practitioners who are licensed by State or Federal laws and also that the decision to follow or reject this program is left to my own discretion.

In addition I fully and completely understand that you do NOT treat nor do you make any recommendations for the treatment of disease in any form or in any manner whatsoever and I wish to assure you that I am in no way asking for such advice or treatment. And that I take full responsibility in choosing to use this facility to help cleans my body.

Again I wish to state that I clearly understand that this analysis and consultation is not meant to take the place of any other form of analysis, counseling or diagnosing by my regular physician or any other licensed doctor or practitioner.

Respectfully your,

_________________________________
Signature

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Address

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Telephone

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