Nutrition Intake Form

I acknowledge that I am aware that Jodie Kreifels, CNC and Ambassador Wellness Center, LLC, its members, officers, agents, employees and independent contractors are not medical doctors and do not diagnose disease.  I also acknowledge that I have been warned that I should consult a Physician before undergoing any dietary or food supplement changes.  I also affirmatively state that I have disclosed any and all known medical or genetic conditions, medications I use, and any significant personal or family medical history. Any recommendations that I follow for changes in diet, including but not limited to the use of food supplements, are entirely my choice and my responsibility. I am knowingly assuming any risk associated with nutritional counseling.  

In consideration of my participation in nutrition counseling, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release Jodie Kreifles, CNC Ambassador Wellness Center, LLC and its members, officers, agents, employees and independent contractors from any liability whatsoever to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness, injury or other harm to my person, including my death, that may result from or occur during my participation in nutrition counseling, whether caused by the sole or concurrent negligence of Jodie Kreifels, CNC or Ambassador Wellness Center, LLC, its members, officers, agents, employees and independent contractors. 

 I further agree to indemnify and hold harmless Jodie Kreifels, CNC and Ambassador Wellness Center, LLC, it’s members, officers, agents, employees and independent contractors, to the fullest extent permitted under law, from any and all liability for the injury of death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described nutrition counseling session.

 I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTIONS FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN NUTRITION COUNSELING AND OR DEATH OF ANY PERSON AND DAMAGE TO P ROPERTY CUASED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMMISION.