CONSENT FORM

NUTRITIONAL INFORMED CONSENT

Nutritional Consult 2002 Binz Street Houston, TX 77004

According to the Federal Food, Drug & Cosmetic Act, as amended, Section 201 (g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.”

Vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy.

Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone.

Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as any primary treatment & or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological & bio-mechanical processes of the human body.

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(If Minor, signature of parent of guardian required) __________________________________________________________

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HOW IT WORKS?

How the program works:

Simply answer the health assessment questions submit, we will contact you by email or phone to set up an appointment with the doctor, the first 15 minutes are free when you decide to continue with our care and program Then you agree and pay $199. to make you two 30 minutes appointment First 30 minutes to go over symptoms and second 30 minute for finding and protocol. If you agree to continue the program and protocol the $199 will be used toward purchase of supplement and herbs indicated by the doctor. Please understand the amount of supplementation are different case by case so we do not know how much until your second visit.

There are other cost may apply if it has been used lab works such as blood, Hair, Saliva, the fees are added at the time of second consultation. Our lab fees are very affordable compare to other nutritional offices. For example Comprehensive Metabolic Panel is $25. and CBC$15 if ordered together.

MAKE AN APPOINTMENT

All appointment available by Phone, Skype or in our clinic.