Agreement to do a Nutrition Response Testing™ Program

I specifically authorize Energy Healing Systems, inc to use a Nutrition Response Testing  health analysis and to develop a natural, complementary health improvement program for me. This program, which may include dietary guidelines and nutritional supplements, will be developed in order to assist me in improving my health, and not for the treatment, or ‘cure’ of any disease.
I understand that Nutrition Response Testing is a safe, non-invasive, natural method 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 this is not a method for the ‘diagnosing’ or ‘treating’ of any disease, including the 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 this testing or any natural health or nutritional programs recommended. I further understand that this testing is 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.
I understand that I am need to adhere to the program guidelines.  These guidelines have been fully laid out before me and discussed in detail.  If I do not fully comply, I understand that this will greatly impact my results and success.
I have read and understand the foregoing.
This permission form applies to all subsequent visits and consultations.

PATIENT PRINT NAME                PATIENT SIGN NAME                      DATE

WITNESS PRINT NAME                WITNESS SIGN NAME                      DATE

WAIVER OF LIABILITY TO DECLINE DOING A NUTRITION RESPONSE TESTING™ PROGRAM

I understand that my testing at Energy Healing Systems, inc. shows my health status is significantly diminished.  It has been thoroughly explained to me by Energy Healing Systems, inc. why I should do a nutritional program in order to improve my health.  I hereby state that I am of sound mind and I am making a conscious decision to DECLINE care.  I will not hold Energy Healing Systems, inc. or any of its associates responsible for any outcome which may result from any symptom or disease process that could occur or be diagnosed by a medical professional.  I hereby release Energy Healing Systems, inc. from any liability regarding my health matters.
I have read and understand the foregoing.

PATIENT PRINT NAME                PATIENT SIGN NAME                      DATE

WITNESS PRINT NAME                WITNESS SIGN NAME                      DATE

NOT A ‘NUTRITIONAL CASE’ WAIVER OF LIABILITY

I understand that my health status may be declining. I have been encouraged by Energy Healing Systems, inc. to seek medical attention for my health issues.  I understand that doing a program at Energy Healing Systems, inc. would not successfully address my current health situation. I will not hold Energy Healing Systems, inc. or any of its associates responsible for any outcome which may result from any symptom or disease process that could occur or be diagnosed by a medical professional.  I hereby release Energy Healing Systems, inc. from any liability regarding my health matters.
I have read and understand the foregoing.

PATIENT PRINT NAME                PATIENT SIGN NAME                      DATE

WITNESS PRINT NAME                WITNESS SIGN NAME                      DATE

Copyright © 2005.  Freddie Ulan.  All rights reserved.  Printed in U.S.A.