Home Patient Forms Ideal Protein Health Profile Form
I hereby consent to act as a participant in a weight control program involving the use of Ideal Protein and other supplements. I understand that various representatives of BioIntelligent Wellness may provide this to me. If I have any questions about this or need further explanations, I understand that I should speak with my medical provider.
I have been informed that the possible benefit and value of this treatment is not guaranteed. I understand that there are many alternative treatments or procedures that are appropriate and available that might be beneficial to me. Some of those alternatives or choices include but may not be limited to:
I understand that I have the right not to participate in this program or to discontinue it after I have begun, for any reason whatsoever. After not following the program for 6 weeks, should I decide to reenter the program I will be expected to pay the initial consultation fee.
This program requires that I purchase the required Ideal Protein foods and supplements, as required by the diet, and I understand I must purchase products from this clinic.
I understand that I have the right to ask questions and to know the purpose and objectives of my treatment program.
Having read this page, I hereby consent to this program. I have been instructed on the ideal protein diet, my health profile has been reviewed and I am aware of possible side-effects related to the diet. I have had adequate time to ask any questions and understand the answers provided.
Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client’s health status in order to guide his or her weight loss plan. A client may be advised to seek medical advice based on his or her health profile.
Please list all medications and supplements you are currently taking
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