Assumption of Risk and Release of Liability and NDA
I hereby acknowledge and agree:
1. The purpose of this consultation is to improve the overall health and well-being of the body through nutritional advice and possibly dietary and supplement recommendations. I acknowledge that Melissa Coffman - The Nutritional Advisor, does not diagnose diseases, disorders or conditions.
2. I acknowledge that Melissa Coffman - The Nutritional Advisor, is not a licensed Medical Physician or licensed Naturopath. She is an accredited nutritionist and .
3. As part of the consultation services, I may be asked to provide information concerning my physical habits, medical history, moods, energy levels, test results, likes and dislikes, lifestyle and diet. This information is collected to enable Melissa Coffman - The Nutritional Advisor to: assess my knowledge of nutrition, education me about the benefits of sound nutritional practices and recommend dietary changes to improve my general health and overall well-being. Melissa Coffman - The Nutritional Advisor, will hold this information in confidence and will not release or disclose this information to any other person, without my prior consent, except as required by applicable law.
4. If Melissa Coffman - The Nutritional Advisor, suspects the existence of disease, disorder or condition, I will be informed of this suspicion. However, I acknowledge this is not a diagnosis or conclusion about the state of my health and that I am directed to promptly consult a licensed Medical Physician or licensed Naturopath about any suspected problems.
5. I give Melissa Coffman - The Nutritional Advisor my permission to recommend lifestyle and dietary changes and/or nutritional supplements in order to help guide me in living a successful healthier lifestyle. I realize that it is my responsibility to disclose the nature of any medical disease, disorder or condition and all other relevant details to Melissa Coffman - The Nutritional Advisor. If I have not previously consulted a licensed Medical Physician or licensed Naturopath about this disease, disorder or condition, I acknowledge that I am directed to promptly do so. I am not to alter or discontinue treatments prescribed by a licensed Medical Physician or licensed Naturopath, or other licensed health professional without consulting the individual who prescribed the treatment.
6. I confirm that I am not currently working with a licensed Medical Physician or licensed Naturopath specifically regarding my diet and nutritional needs.
7. In providing advice and recommendations to me, Melissa Coffman - The Nutritional Advisor, is relying upon the truth, accuracy and completeness of all information I have provided to her. Any recommendations I follow for changes in diet, including the use of nutritional supplements, are entirely my responsibility.
8. Melissa Coffman - The Nutritional Advisor is in no way liable for my health or safety.
9. In consideration of my participation in a nutritional consultation, I hereby accept all risk to my health, including injury or death that may result from such participation and I hereby release Melissa Coffman - The Nutritional Advisor, on my behalf and on behalf of my personal representatives, estate, heirs, next of kin, and assigns from any and all costs, claims, causes of action and damages arising from any and all illness or injury to my person, including my death, that may result from or occur as a result of my participation in her services, whether caused by negligence or otherwise.
10. I understand that any regimens I undertake through Melissa Coffman - The Nutritional Advisor are undertaken of my own free will. I accept that the ultimate responsibility for my health care is my own and that Melissa Coffman - The Nutritional Advisor is here to support me in this. I understand that my practitioner reserves the right to determine which cases fall outside their scope of practice, in which event an appropriate referral will be recommended. I hereby agree to assume full responsibility for any manner of loss, injury, claim or damage whatsoever, known or unknown, incurred as a result of same and I, my heirs, executors, administrators or assigns for any loss, injury, claim or damage sustained as a result of my attendance and/or participation. I have read the above release and waiver of liability, and fully understand its contents and voluntarily agree to the terms and conditions stated.
11. Information disclosed during any consultations, emails or other means, by either party to the other party under this Agreement is considered confidential and proprietary and cannot be shared. Confidential and proprietary information provided by Melissa Coffman - The Nutritional Advisor is meant for the recipient and cannot be shared or used by any other business or individual. These terms do not expire.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTOOD IT TO BE A FULL AND FINAL RELEASE OF ALL COSTS, CLAIMS, CAUSES OF ACTION AND DAMAGES OF ANY KIND ARISING FROM OR IN CONNECTION WITH THE MELISSA COFFMAN, THE NUTRITIONAL ADVISOR.
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SIGNATURE DATE
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PRINTED NAME
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PRINTED NAME OF MINOR (if applicable) MINOR’S DATE OF BIRTH (01/01/0001)
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RELATIONSHIP TO MINOR