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DONNA F. SMITH, C.C.N., C.N. WILLIAM
H. BRELAND, P.T., S.C.S. ROBERT J. WOLFF, D.C. T. ROGER HUMPHREY, M.D.  Advanced
Clinical Nutrition
Donna F. Smith |
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Informed Consent
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I acknowledge with my signature below that I have read, understood, and agree to the contents of the Informed Consent and am retaining the clinical and sports nutrition services of Advanced Clinical Nutrition, Wichita Falls, Texas, through their Internet Web Site, Women's Sports Nutrition. I further acknowledge that I may discontinue these services at any time without further obligation or commitment.
| 1. | I understand that Clinical Nutrition is a specialization in the science of nutrition, and the services provided are to assess and evaluate my health as it relates to nutritional deficiencies, insufficiencies, and excesses; biochemical, bioelectrical and metabolic imbalances; food and environmental allergies and sensitivities and other assessments or evaluations which lie within the scope of the science and practice of clinical nutrition. |
| 2. | I further understand that Advanced Clinical Nutrition may interpret and utilize laboratory and/or other evaluation techniques designed to assist in clinical and sports nutrition assessment. |
| 3. | I understand that after completing the requirements for a clinical and sports nutrition analysis or assessment, I will receive recommendations for a clinical nutrition program of care which may include, but is not limited to, specific foods, vitamins, minerals, amino acids, herbs and other food supplements or substances to assist my body in correcting nutrient deficiencies, biochemical and metabolic imbalances, and to support my biological weaknesses or dysfunctional organs, glands or body systems. |
| 4. | Advanced Clinical Nutrition may also coach me in how to build and maintain my health through personalized lifestyle education consultations and articles, called "P.E.P. Sessions." |
| 5. | I understand that each nutritional assessment, recommendation and program of care is for the purpose of providing nutritional support and assistance to the body's innate healing response towards homeostasis, and is not for the diagnosis, treatment, or prescription for any disease, disorder or condition of the body. |
| 6. | If I have a disease, disorder or condition of the body, I understand that I must seek medical attention, and that I am now being advised to do so. I also understand that should my nutritional assessment and evaluation indicate health problems which lie outside the scope of clinical nutrition, Advanced Clinical Nutrition will immediately refer me to the appropriate healthcare provider. I further understand that should this occur, I may request that Advanced Clinical Nutrition work with other healthcare professionals to provide nutritional support for my body and to complement any other treatment I may choose for optimum health. |
| 7. | I understand that non-nutritionally, related factors can interfere with the effectiveness of my clinical and sports nutrition program of care. Therefore, I understand that there are no guarantees regarding the success of my program of care. |
| 8. | I further understand that in some cases, several adjustments in my program of care may be necessary before I experience successful results. This being the case, I agree that the best insurance I have for success is to follow precisely all recommendations made by Advanced Clinical Nutrition and to communicate regularly as required so that timely adjustments can be made to my program. |
| 9. | I further agree to withhold my evaluation of the effectiveness of my program of care until I have followed my clinical nutrition program recommendations consistently for a minimum of three months. |
| 10. | I agree to hold Advanced Clinical Nutrition/Women's Sports Nutrition blameless in all regards to my clinical and sports nutrition program of care. |
To avoid delays in processing your analysis, after completing the Informed Consent, print, sign and fax immediately to (940) 761-2881 and then mail the Informed Consent with your original signature to:
Advanced Clinical Nutrition
1911 Tilden St.
Wichita Falls, Tx 76309-3119
Copyright, 1999 Donna F. Smith