Name (Last, First): ________________________________________________________ Date (MM/DD/YEAR): ______________
I hereby consent to treatment and guidance while on the ChiroThin™ weight loss program. The ChiroThin™ Weight Loss Program is a Chiropractor-supervised weight loss program that is designed to maximize weight loss by using specific combinations and blends of specific low glycemic index/anti-inflammatory foods in combination with the ChiroThin™ nutritional support formula. I agree to follow the program designed or modified by the ChiroThin™ supervising health provider. I further agree to attend all scheduled weekly appointments. I understand that up to 6 appointments are included in the price of the entire program. I also understand that the cost of the program is designed to include the cost of supervision, program materials and supplies.
___________ (Patient Initials) ___________ (Doctor Initials)
I agree to the following:
• I will eat every component of every meal as described.
• I will not skip any meals.
• I will take my drops as scheduled and will not miss taking them.
• I will not drink alcohol.
• I will take a daily multi vitamin and daily fiber tablets (to be approved by supervision doctor if not provided).
• I will not take any Essential Fatty Acid supplements while on the ChiroThin program.
• I will fill out my daily journal to be reviewed at the weekly sessions.
• I will drink my daily amount of recommended water.
• In order to achieve my desired goals, I agree not to quit or give up.
• I will be honest with myself and agree NOT TO DO things that are not in alignment with the program.
___________ (Patient Initials) ___________ (Doctor Initials)
I understand that once I have started my weight loss program there are NO refunds. I also understand that my program is NON-transferable. I understand that weight loss is NOT GUARANTEED with this program, but that other patients have experienced positive results while on the program.
___________ (Patient Initials) ___________ (Doctor Initials)
I understand that I undertake this program entirely at my own free will and risk and that my doctor will endeavor to take all due care. I understand that my doctor will rely on statements made by me to determine that the program is safe and will be effective for me. I have informed the doctor of all known physical and medical conditions as well as all medications that I am currently taking. I assume all responsibility and liability for any condition(s) or medication(s) I have failed to disclose.
___________ (Patient Initials) ___________ (Doctor Initials)
I hereby waive any potential claim for liability against the doctor and the makers of ChiroThin, and freely accept all liability and responsibility for my results while on this program.
Patient Signature: ______________________________________________________________________________________
Witness Signature: ______________________________________________________________________________________