Alka-Clean Detox and Tissue Regeneration Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Cell Phone Number*

Area CodePhone Number

E-mail*

Height

Age

Weight

Current and past health conditions and symptoms

Current diet and lifestyle

List example of breakfast, lunches, snacks, dinners

Current medications

Food allergies

On a scale of 1-10 with 1 being the lowest and 10 being the highest, what is your level of motivation and determination to heal yourself?

Waiver and Release of Liability

In consideration of Alka-Clean Detox and Tissue Regeneration L.L.C. agreement to instruct, assist, I hereby agree to hold harmless Alka-Clean Detox and Tissue Regeneration L.L.C., its respective representatives, executors, agents, and assigns from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected to my participation in any and all activities, use of Equipment, or any and all acts or omissions, including negligence by Alka-Clean Detox and Tissue Regeneration L.L.C. and his representatives. This waiver and release of liability includes, but is not limited to, (a) Injuries and Changes to myself and/or others, including but not limited to Alka-Clean Detox and Tissue Regeneration L.L.C., that may occur as a result of (i) Equipment that may malfunction or break; (ii) any and all defects, latent or apparent, in the design or condition of Equipment; (iii) any and all slips, falls, or dropping of Equipment; (iv) any and all improper maintenance of equipment or facilities; (v) any hazardous condition that may exist on the premises, including, but not limited to, the specific workout area; and (vi) Alka-Clean Detox and Tissue Regeneration L.L.C.  negligent instruction or supervision; (b) damage to property, including but not limited to, Equipment and the premises.

Conclusion
I acknowledge and agree no warranties or representations have been made to me regarding the results I will achieve from this program. I understand results are individual and may vary. I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims, its respective representatives, executors, and/ or assigns. I represent and warrant I am signing this agreement freely and willfully and not under fraud or duress. I further represent and warrant no social relationship exists between Alka-Clean Detox and Tissue Regeneration L.L.C. and me, or if such a social relationship exists, for any services or advice, Alka-Clean Detox and Tissue Regeneration L.L.C. and I have assumed a strict business relationship, and I understand any social relationship does not render this waiver invalid. These exculpatory clauses are intended to apply to any and all activities occurring during the time for which I have contracted with Alka-Clean Detox and Tissue Regeneration L.L.C., and is not a licensed dietician, physician, nutritionist company or service.

The client is responsible for managing food allergies. The contents of this document and the programs Alka-Clean Detox and Tissue Regeneration L.L.C. creates should not be taken as medical advice. It is not intended to diagnose, treat, cure, or prevent any health problem nor is it intended to replace the advice of a physician. Always contact your health professional before beginning any exercising or dieting program. All contents shared with Alka-Clean Detox and Tissue Regeneration L.L.C. will not be copied, sold or redistributed without consent.

You acknowledge that after making a payment, you are in acceptance of this entire release and liability agreement and that your payment constitutes an approval signature of this agreement in its entirety.

What’s included in the program?
Clients will receive weekly workout programs. Programs will change based on client response, not every week will change. Clients will be given exercises along with their sets and rep ranges. Alka-Clean Detox and Tissue Regeneration L.L.C. is not a licensed nutritionist or dietician and therefore cannot provide structured meal plans. I will do my best by giving recommendations on what foods will best suit your goals and we will work on this together to make sure you are seeing results. Clients also have the freedom to email me any questions or concerns they may have. Clients will be responded to as quickly as possible.

Payments
There are no contracts. All transactions are final. I certify that I am the authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company. All credit/debit card information will be discarded after the first payment is submitted. Subsequent credit/debit card information will be stored with the credit card vendor for security purposes. I authorize Alka-Clean Detox and Tissue Regeneration L.L.C. to charge the credit card listed. Please fill out the following:

INDEMNIFICATION
You agree to indemnify, defend and hold harmless Alka-Clean Detox and Tissue Regeneration L.L.C., and any subsidiaries, affiliated companies, third-party service providers and each of their respective officers, directors, employees, shareholders, and agents (each an “indemnified party” and collectively, “indemnified all parties”) from and against any and all claims, damages, losses. liabilities, suits, actions, demands, proceedings (whether legal or administrative), and expenses (including, but not limited to, reasonable attorneys’ fees) threatened, asserted, or filed by a third party against any of the indemnified parties arising out of, or relating to: (i) your use of the Services; (ii) any violation by you of any of our policies; (iii) any breach of any of your representations, warranties or covenants contained in this Agreement; or (iv) any acts or omissions by you. The terms of this section shall survive any termination of this Agreement. For the purpose of this paragraph only, the terms used to designate you to include you, your customers, visitors to your website, and users of your products or services the use of which is facilities by us.

ASSIGNMENT OF CONTRACT
Neither of the parties may assign this agreement or any rights under the agreement without the prior written consent of the other party.

GOVERNING LAW
This agreement is governed by the laws of the state of Arkansas and any applicable federal laws of the United States of America.

LEGAL EXPENSES
If any legal action is necessary to enforce the terms of this agreement, the prevailing party shall be entitled to reasonable attorney fees in addition to any other relief to which that party may be entitled.

FORCE MAJEURE
If performance by us of any of our obligations under the terms of this agreement shall be interrupted or delayed by an act of God, by acts of war, riot, or civil commotion, by failure of computer equipment, including loss of data, or by an act of State, by strikes, fire, flood, or by the occurrence of any other event beyond our control, then we shall be excused from such performance for the same amount of time as such occurrence shall have lasted or such period of time as is reasonably necessary after such occurrence abates for the effect of the occurrence to have dissipated.

ACCEPTANCE OF AGREEMENT
By ordering our services, completion of such a transaction indicates your acknowledgment that you have read, understood, and accepted this agreement and any/all other published or unpublished terms or waivers disclosed or not disclosed.

Any information shared by Alka-clean Detox and Tissue Regeneration including (but not limited to) diet, iris analysis, nutrition, herbal, homeopathic, fasting, detoxing, tissue regeneration or any other health modalities, is solely for educational purposes and does not involve or include diagnosing, prognosticating, treatment, or prescribing of remedies for the treatment of diseases and should not be considered a substitute for medically necessary diagnostics. Alka-clean Detox and Tissue Regeneration who provides services for information does so as empowerment and guidance coaching and is not in the capacity of a licensed healthcare provider.

All purchased consultations must be used within one month of purchase or the client will forfeit that purchase.

Please choose one ore more from the list below*

Initial Consultation90 Minute initial consultation plus iris analysis

$150.00

Initial Consultation (VIP)90 Minute initial consultation plus iris analysis

$100.00

First Follow Consultation

$75.00

Continued Followup Consultations

$50.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Alka-Clean Detox and Tissue Regeneration Client Signup: