The Energy Remedy
26689 Pleasant Park Rd. Conifer, CO 80433
303-838-9355
PERMISSION & AUTHORIZATION FORM
REGARDING THE USE OF A HEALTH IMPROVEMENT PROGRAM
PLEASE READ BEFORE SIGNING:
I specifically authorize Terence Trinka at The Energy Remedy to perform a health analysis and to develop a natural, complementary health improvement program for me which may include dietary guidelines, nutritional supplements, ect. in order to assist me in improving my health, and not for the treatment, or "cure" of any disease. I hereby acknowledge that Terence Trinka is not a licensed medical doctor and does not practice medicine. Terence does not treat specific diseases or medical conditions and does not provide medical diagnosis or medical case management.
I understand that all information provided to me and my health care practitioners by Terence Trinka and/or his staff via telephone consultations, laboratory reports, audio and/or video tapes, written materials and all other means is provided for my health awareness, nutritional and lifestyle education purposes only. It is not intended for "diagnosing" or "treating" of any disease or medical condition.
No promise or guarantee has been made regarding the results of any natural health, nutritional or dietary programs recommended. I understand that as a condition of any agreement to provide services to me, I agree to waive any and all claims, causes of action and lawsuits that I may have, believe that I have, now or at any future date against Terence A. Trinka and/or The Energy Remedy for services already provided or to be provided in the future. I further understand that this program is a means by which these tools can be used as an aid to determining possible nutritional imbalances, so that safe and natural programs can be developed for the purpose of bringing about a more optimum state of health.
No refunds on nutritional supplements after 30 days from purchase or if opened.
I have read and understand the foregoing.
This permission form applies to subsequent visits and consultations.