Informed Consent, Private License & Release Therapies to Balance the Body for Homeostasis The undersigned herby grants a Private License to the Practitioner, Nadia Martinez, to provide nutritional evaluation and recommendations with the undersigned as expressive association activities. The undersigned acknowledges that the Practitioner is not a licensed dietitian and does not diagnose or prescribe for medical or psychological conditions nor claim to prevent, treat, mitigate, or cure such conditions, nor provide diagnosis, care, treatment or rehabilitation of individuals, nor apply medical, mental health or human development principles, but rather provides traditional, bioenergetic, magnetic, herbal and/or nutritional modalities that may offer therapeutic benefit by supporting normal structure and function. The undersigned gives Informed Consent to the services that will be provided. The undersigned herby releases the Practitioner from all claims and liabilities arising from the use or misuse of traditional, spiritual, mental, bioenergetic and/or nutritional modalities, indemnifying and holding the Practitioner harmless from all claims and liabilities therefrom whatsoever. The Practitioner reserves all rights. Permission is given to use any information about me for research and publication so long as all personal identification is masked. Date * MM DD YYYY Electronic Signature * Please provide your full name. Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Thank you!
