AGREEMENT AND RELEASE OF LIABILITY
AGREEMENT AND RELEASE OF LIABILITY: The health and nutritional information you receive from Serina Vassar, NTP of Wise Bear Functional Nutrition, LLC, whether given by phone, in person at your home, in the Wise Bear Functional Nutrition, LLC office, through lectures, workshops, brochures, emails, website, or newsletters is not intended to diagnose, prescribe, treat, cure, alleviate, prevent or care for any disease in any way. It consists of combined information from many educational sources and points of view to help you make informed decisions regarding your desired level of health. The sources behind this information include: modern medicine, ancient Chinese medicine, naturopathic medicine and the therapist’s personal research, study, educational materials from the Nutritional Therapy Association, Ulan Nutritional Systems, and life observation as well as patient results and experiences. Anyone deciding to act upon any information mentioned during a consultation shall assume full responsibility for any effects of their actions. There are risks and unforeseen results associated with any change of diet and lifestyle. It is not recommended that you apply these changes unless you are willing to assume full responsibility for the risks you choose to take. If you choose to implement dietary and lifestyle changes without consulting your physician, which is your constitutional right, you are, in effect, prescribing for yourself. When in doubt of the appropriateness of any treatment, whether recommended to you by a clinician/ practitioner or by your own intuition, please consult a physician. Consultation information should not be used as a substitute for a physician’s advice. It is our hope that you do choose a physician who realizes the importance of a healthy diet and lifestyle choices in correcting imbalances in the body and who has experience in treating immune disorders and other health imbalances. Please be aware that you have the right to make your own health decisions based on any information made available to you. YOU are the driving force in guiding yourself on a path to health! *
ACKNOWLEDGEMENT: I understand that Muscle Response Testing and Nutritional Therapy are safe, non- invasive, natural methods of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalances in these areas could cause or contribute to various health problems. I understand that Muscle Response Testing and Nutritional Therapy are not a methods for “Diagnosing” or “Treating” any disease including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated. No promise or guarantee has been made regarding the results of Muscle Response Testing, Nutritional Therapy, or any natural health, nutritional or dietary programs recommended, but rather I understand that Muscle Response Testing and Nutritional Therapy are a means by which the body’s natural reflexes can be used as an aid to determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health. *
ACKNOWLEDGEMENT: In consideration of being allowed to participate in programs, modalities, and activities of Wise Bear Functional Nutrition, LLC and to use its facility in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge Wise Bear Functional Nutrition, LLC and its directors, officers, agents, employees, representatives, successors and assigns, administrators, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from my participation in any activities or my use of equipment or machinery. I do also hereby release all of these mentioned and any others acting upon their behalf from any responsibility or liability from any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of Wise Bear Functional Nutrition, LLC. I understand that Carone Chiropractic Center, and Nicholas Carone, DC is a separate entity and would not liable for any legal action that may be incurred by Wise Bear Functional Nutrition, LLC, Serina Vassar, NTP. *
ACKNOWLEDGEMENT: I have read and understand the foregoing. Intending to be legally bound, I hereby release Wise Bear Functional Nutrition, LLC from any liability, including for negligence, regarding my health matters and my participation in Muscle Response Testing, Nutritional Therapy, or any other program. This release applies to all subsequent visits for programs, modalities and activities at Wise Bear Functional Nutrition, LLC. By my/our signature(s) below, I/we confirm that I/we have read and fully understand the above disclaimer, are in complete agreement thereto and do freely and without duress sign and consent to all terms contained herein: *
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