Assumption of Risk and Release of Liability

Please review the following assumption of risk and release of liability agreement carefully before signing.

I hereby acknowledge and agree:

1. The purpose of nutritional counselling is to improve the overall health, vitality and well-being of the body through nutritional education and the use of natural foods and non-medicinal nutritional supplements. The practitioner does not diagnose diseases, disorders or conditions.

2. The practitioner is not a licensed Dietitian, Naturopathic Doctor or Medical Physician.

3. As part of the Nutritional Counselling Services, I may be asked to provide information concerning my physical habits, medical history, moods, energy levels, likes and dislikes, lifestyle and diet. This information is collected to enable the practitioner to: (i) assess my knowledge of nutrition, (ii) educate me about the benefits of sound nutritional practices and (iii) recommend dietary changes to improve my general health, vitality and overall well-being. The practitioner 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 the practitioner suspects the existence of a 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 Physician or Naturopath about any suspected problems.

5. Should I request the practitioner to recommend dietary changes and/or nutritional supplements to enhance my body’s natural ability to resist and/or overcome a known disease, disorder or condition, it is my responsibility to disclose the nature of the disease, disorder or condition and all other relevant details. If I have not previously consulted a licensed Physician or 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 Naturopath, Physician or other licensed health professional without consulting the individual who prescribed the treatment.

6. In providing Nutrition Counselling Services to me, the practitioner is relying upon the truth, accuracy and completeness of all information I have provided. Any recommendations I follow for changes in diet, including the use of nutritional supplements, are entirely my responsibility.

7. The practitioner and practice are in no way liable for my health or safety.

8. In consideration of my participation in the Nutritional Counselling Services, I hereby accept all risk to my health, including injury or death that may result from such participation, and I hereby release the practitioner and the practice, 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 the Nutrition Counselling Services, whether caused by negligence or otherwise.

9. A minimum of 24 hours notice is required for cancelling or rescheduling appointments. Appointments cancelled within 24 hours of the scheduled time may be billed at up to 100% of the service fee.

10. I understand that any therapies I undertake are undertaken of my own free will. I accept that the ultimate responsibility for my healthcare is my own. 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 release the practice, its practitioners, heirs, executors, administrators or assigns from any liability.

Client Signature * Required

Signature

I HAVE CAREFULLY READ THIS AGREEMENT AND AGREE TO THE TERMS OUTLINED ABOVE. I UNDERSTAND THIS AGREEMENT 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 NUTRITION COUNSELLING SERVICES.

Assumption of Risk and Release of Liability

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