You Can Heal You

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Initial Visit Questionnaire

I appreciate the opportunity to meet with you to discuss my concerns. You have made it very clear, and I acknowledge that I am to read and sign this agreement and reserve my appointment with a $25.00 non-refundable deposit that will be credited toward my consultation. I am to personally bring or send through mail the completed questionnaire on pages 2-10. Payment in full is due at the time of service.

1) The opinions, advice, and services you offer are primarily educational guidance and not medical advice, and under no circumstances are to be considered by me as such;

2) The opinions, advice, and services that you offer are under no circumstances intended to modify, affect, or to be in lieu of any medical advice or treatment that I may require for any cause whatsoever, now or in the future;

3) You encourage me to consult with my doctor with reference to my particular problem and to keep my doctor fully informed as to the opinions, advice, and services you offer;

4) Your opinions, advice, and services fundamentally relate to an educational program pertaining to the teaching of a more macrobiotic, natural, and traditional diet including nutritional and related principles which many people have found helpful for improving their physical, mental, and spiritual conditions;

5) You have made no promise or representations, expressed or implied, as to any result I might obtain by adhering to your opinions or advice or in accepting your services.

6) I, together with any and all accompanying persons, have completely read the above statements, and acknowledge that I/we fully understand them, and that I/we have received no promises or guarantees whatsoever. I understand that the success of the program is dependent upon many factors including my
cooperation.

I, for good and valuable consideration, release and discharge Virginia M. Harper, You Can Heal You, the officers, employees, representatives, cooks, and agents, from any and all claims and demands of every nature which I now have or may have in the future as a result of accepting and following the advice, opinions, and services offered by Virginia M. Harper and You Can Heal You representatives.

Important: Your name indicated on this line below will stand in as your signature