Waiver
Please read each statement below and type your full name stating you acknowledge and agree to each. When complete, please sign your name at the bottom then submit form.
I consent to participate voluntarily in ASD Health Coach's services and I recognize this Program may contain certain inherent risks. I expressly assume the risks of the services and I take full responsibility for my child's life and well-being and all decisions made before, during and after using these services. I agree to observe and obey all posted rules and warnings, and further agree to follow any instructions or directions given by ASD Health Coach, Becky Davila.
I understand that the information provided at or in conjunction with the ASD Health Coach services, including dietary recommendations and/or supplement advice is not intended to be a substitute for professional medical advice, diagnosis or treatment that can be provided by my physician, therapist, licensed dietitian or nutritionist, or any other licensed or registered health care professional.
I understand that the health coach of ASD Health Coach is not a medical or mental health care provider and is not providing health care, medical or nutrition therapy services or attempting to diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. Rather, they are serving only in their capacity as coaches, educators, mentors and guides.
I agree to seek the advice of my child's pediatrician, physician or another qualified health care professional prior to and during services regarding any questions or concerns I have about my child's specific health situation, known or suspected food sensitivities or allergies, dietary restrictions, or any medications I am currently taking. I agree to not disregard professional medical advice or delay seeking professional advice or start/stop taking any medications without speaking to my child's pediatrician, physician or health care professional.
I agree to disclose to ASD Health Coach in advance of any known or suspected food allergies or sensitivities, or any other health or mental condition that may be affected during the treatment program. If I suspect that my child is having a medical problem, I agree to inform ASD Health Coach immediately.
I understand that no claim is made as to the certain efficacy of any nutritional or supplement protocols. I understand that adopting any of these recommendations to implement for my child is voluntary and by choice.
I also understand that in some cases lab testing may be recommended as well. If I choose to engage in lab testing for my child, I voluntary consent to such testing and I fully understand and agree that ASD Health Coach is not acting as a medical practitioner or providing medical therapy services in any way. I understand and agree that lab testing results and recommendations are not attempting to diagnose, treat, or cure, in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. Rather, I understand and agree that the lab testing results are shared with me for purely educational and informative purposes.
Any information that is obtained from my medical history, treatment plans and coaching services will be treated as privileged and confidential and will not be released or revealed to any person other than my healthcare providers without my expressed written consent.
In the event that my child becomes ill or injured as a result of my participation in ASD Health Coach's services, I hereby release, discharge, and waive any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands which I have ever had, now have, and could have in the future against Rebecca (Becky) Davila and/or ASD Health Coach, arising from my participation in anything related to these services, now or in the future.
I have carefully read this document and by signing below I consent to all parts of it. I understand that by signing this release, I voluntarily surrender certain legal rights.
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