Consent Form

By clicking each 'Agree' checkbox below, I hereby acknowledge that I have read and understand clearly the terms and their significance. No oral representations of inducements have been made to me to sign this form. By agreeing to all terms and submitting this form electronically, I confirm it is a form of providing my signature.

Today's Date:(Required)

Personal Information

Name(Required)

First Last

Birthday(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Terms/Consent Items

Consent #1(Required)

Agree

I fully understand that the Health and Wellness Consultant I am seeing in-person or by-distance is not a physician, and I am not consulting for medical, diagnostic, or treatment procedures.

Consent #2(Required)

Agree

The services performed by the Health and Wellness Consultant are at all times restricted to helping me gain a better understanding of my degree of "health"; (not disease), so I will have a greater self- awareness and be able to use a self-care program for daily living.

Consent #3(Required)

Agree

I understand that the recommendations, discussion, sale of food, nutrition, nutritional supplements, vitamins or minerals, food grade herbs, or other nutrients as foods for special dietary use only pertains to the whole body concept of nutrition, and does not relate in the context of any specific ailment, condition, and/or treatment and diagnose of ailments.

Consent #4(Required)

Agree

The in-person or by-distance appointments do not involve the diagnosing, prognosticating, treating or prescribing of medicines or the treatment of disease, or any act which will constitute the practice of medicine in this state, for which a license is required.

Consent #5(Required)

Agree

I recognize the fact that it is my responsibility to work directly with my physician before, during, and after seeking fitness and nutrition consultation. As such, any information provided is not to be followed without the prior approval of my physician. If I choose to use information and participate in physical activities without the prior consent of my physician, I am agreeing to accept full responsibility for my decision.

Minor: Under 18 Years of Age

Are you under 18?(Required)

If you're a minor (under the 18 years of age), you are required to have a parent or guardian provide name and email below. By entering his/her name and email, I attest to have communicated and discussed this consent form with my parent or legal guardian.

Name (parent/guardian)(Required)

First Last

Enter here the name of the parent of guardian of minor

Email (parent/guardian)(Required)

Please list the parent or guardian's email.

Newsletter Opt-In

Newsletter Opt-In(Required)

By saying YES, you are consenting to receive occasional newsletters with awesome relevant information and tips on health, wellness, fitness, yummy recipes, local/online events, specials, and more. Don't worry, no spams. To prevent our emails from going to your spam, add BeFabBeYou.com to your safe list.