ACKNOWLEDGEMENT AND CONSENT TO RECEIVE SERVICES:

I, _________________________________________, the undersigned, do hereby acknowledge that _______________________________ is a Health Coach & Life Coach and that they are not a medical doctor or registered primary health care provider, nor are they providing medical services. I will not consider anything they say to substitute in any way for consultation, diagnosis and treatment by a registered primary health care provider, such as an G.P. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor or registered health care provider.

I understand Whole Health Partnership's sole intention is to offer to me educational nutrition information I request. If I choose to use this information to work on myself then I affirm that the responsibility is mine.

I understand Whole Health Partnership to state that one should never use their information in any way that contradicts, conflicts, or opposes a course of treatment recommended by my primary health care provider. If I ever feel that information given by Whole Health Partnership opposes my registered primary care physician's treatment or recommendations, Whole Health Partnership strongly advises me to follow the advice and instruction of my registered primary health care provider.

I affirm my right to self-health and the ability of my own innate intelligence to control my self-healing process. I can heal myself, and maintain holistic health solely through actions I take on my own behalf or through such other channels as a registered medical doctor.

I, the undersigned, do hereby voluntarily state to understand and acknowledge as accurate all the above comments.

Name: _______________________________________________________________
Address: _____________________________________________________________
Phone Number (home):_______________ Phone Number (work): _______________
Signature: _____________________________________ Date: __________________