Real Old Remedies

Client Consent Form

Client Consent Form
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understand that I am here to learn about holistic nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is for educational purposes only.
fully understand that those who counsel me are not medical doctors and I am not here for medical-diagnostic purposes or treatment procedures. For any medical condition, I am advised to seek care from an appropriate medical practitioner.

I also understand that it is my responsibility to discuss any and all information provided during this consultation with my primary health care provider or any other health care providers/specialists whose care I may be under.

I, the undersigned, assume all responsibility for decisions I make regarding my health, recognizing that:

  1. No claims are made for herbal medicine, nutritional or dietary recommendations to treat or cure any medical condition.
  2. All information given is for educational purposes only.
  3. There is no implied or stated guarantee of the success or effectiveness of any specific treatment plan or guidelines.
  4. I am free to act upon or disregard the recommendations of Real Old Remedies Inc. as I so choose.

I hereby release Real Old Remedies Inc. from all responsibility for my actions and any consequences thereof in the present time and in the future with no constraints. I hereby affirm that I consent and agree to the above statements of my own free will and request to engage the services of Real Old Remedies Inc. in a professional relationship pursuant to the statements herein.

Due to privacy regulations, your information will be held confidential and not shared with anyone.

Initial here to indicate that you have been advised of all consultation fees.
Initial here to indicate that you are aware that these services are not covered by insurance and that you are responsible for all fees incurred.
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