Wholistic Health Scan Consultation

CONTRACT OF AUTHORIZATION IN THE DIETARY HEALTH ANALYSIS PROCEDURE AND ENERGY EVALUATION

I hereby authorize blanksa client of to act on my behalf concerning the Dietary Health Analysis Procedure for Energy Evaluation and develop for me a suggested Dietary Health Program. I warrant that all information submitted for analysis and evaluation was submitted by me and is true to the best of my knowledge.

I acknowledge and recognize that the Dietary Health Analysis Procedure, the Evaluation, and the Suggested Dietary Health Program have not been evaluated or approved by the Food and Drug Administration or by the AMA, and are not intended as diagnosis, treatment, care , alleviation, mitigation, prevention, or care of any disease of any kind in any way. However I reserve the right to use the knowledge I gain in the care of my own body in any legal manner I may choose, including the Suggested Dietary Health Program.

I hereby attest and affirm that I am here as a client/student, on this and any subsequent visit, solely on my own behalf and not as an agent for federal, state or local agencies on a mission of entrapment or for any investigative purposes.

Name

First NameLast Name

Email*

example@example.com

Phone Number

Area CodePhone Number

DOB*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Height*

Weight*

Occupation

Allergies*

Type a question*

In order of magnitude, list the areas of your body which are affected most:*

Did your health challenges begin after you were:*

Are you presently in pain now? blanks . if so, where?

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1. Unless legally licensed as a medical practitioner, I fully understand that the Solex Independent Quantum Living Advocate who is assisting me with this analysis using AO Scan Mobile, is simply facilitating the technology.*

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2. Unless legally licensed as a medical practitioner, I fully understand that the Solex Independent Quantum Living Advocate who is assisting me is prohibited from diagnosing or treating any disease, condition, or illness by prescribing medication, offering medical advice, conducting surgery, or providing any other medical services.*

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3. I fully understand that the AO Scan Mobile analysis is strictly educational in nature and does not diagnose, treat, cure, orprevent any disease. *

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4. I fully understand and acknowledge that the AO Scan Mobile uses subtle energy, frequencies, vibration, and resonance tointeract with the body’s energy field and measure my body’s response. When it encounters imbalance, it reports those imbalancesto me and helps optimize my wellbeing by identifying frequencies that may restore balance.*

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5. I fully understand that the analysis provided by the AO Scan Mobile is leading-edge technology and is not yet generallyaccepted by conventional health care professionals. An AO Scan Mobil analysis is not covered by medical insurance*

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6. I fully understand that any payment for an analysis is expected at time of service, unless otherwise arranged prior to my session.*

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7. I acknowledge that the US Food and Drug Administration has not evaluated any statements made regarding the AO ScanMobile. Again, the AO Scan Mobile is not intended to diagnose, treat, cure, or prevent any disease.*

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8. I affirm that I am acting of my own free will and according to the dictates of my own conscience to experience an AO ScanMobile Analysis.*

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9. I affirm that I do not represent, nor am I an agent for, the American Medical Association or any state or federal regulatoryagency.*

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10. I affirm that I am requesting this analysis for myself and not for legal recourse.*

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11. With the acceptance of this consent agreement and liability waiver, I hereby waive and release myself and my hers,executors, and administrators, from any and all claims of any nature whatsoever and do hereby acknowledge that I will use theservices provided at my own risk. I confirm that I have given accurate legal direction and that I am of legal age in this jurisdiction.*

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Date

Signature

Wholistic Health Scan Consultation

BIOENERGETIC STRESS SURVEY

Solex AO Scan Mobile Consultation Consent Agreement and Liability Waiver

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