Electrodermal Screening Informed Consent

Name*

First NameLast Name

Do you use artificial sweeteners (diet soda, splenda, equal etc)?*

How many hours of deep sleep do you get?*

Do you crave salt/sugar? Which one or both?*

List your 3 greatest health concerns in order of significance to you.*

I hereby attest and agree to the following:

1. I fully understand that Lisa Colosi Warren is a natural health advisor who deals strictly in helping people to improve their general health and fitness through better nutrition, improved lifestyle, and health habits.

2. I fully understand that Lisa Colosi Warren is not a licensed physician and cannot diagnose diseases, prescribe drugs or recommend treatments for specific disease conditions.

3. I understand that all evaluations performed by Lisa Colosi Warren are designed to evaluate my inherent constitution and temperament for the sole purpose of helping me to improve my general health through nutrition, habits, and attitudes. I further understand that said evaluations cannot determine specific disease conditions I may have and do not replace the diagnostic services offered by licensed physicians.

4.I understand that Lisa Colosi Warren neither claims nor implies that any instruction, advice, counsel, suggestions, recommendations, services or products she provides, whether in person or by mail or telephone, will cure, treat, prevent or mitigate any disease conditions but are provided solely for the purpose of increasing energy, supporting the natural function of body systems and otherwise improving general health and fitness.

5.I certify that Lisa Colosi Warren has not suggested that I cease any medical care I may be currently undertaking. I understand that the decisions I make regarding my health care and the health care of those under my guardianship are my responsibility and certify that I will not hold Lisa Colosi Warren responsible for the consequences of my decisions.

6. I certify that I am here on this and on any subsequent visit or contact, whether by mail, telephone, or in person, solely on my own behalf and not as an agent or representative of any federal, state, county or local government or private agency on a mission of investigation.

7. I understand that I am responsibile to pay the full appointment fee if I cancel an appointment within 24 hours of the appointment time.

7. I will keep Lisa Colosi Warren informed of any disease or physical limitation I may have or develop, whether discovered by me, my physician, or others. I have read and understand the foregoing and agree to the terms and conditions set therein. I have received a copy of this agreement.

Date*

Signature*

Electrodermal Screening Consent Form