This is an important legal document. It explains the risks you are assuming by starting a wellness program. It is critical
that you read and understand it completely.
The nutrition advice or recipes given by Nicole , are based on the information provided by the client / individual. The nutrition information given is meant only
for the client / individual completing the forms. It is the sole responsibility of the client / individual to provide complete and accurate information.
Any misinformation or omitted information may affect the nutritional/ assessment / advice. Any misrepresented information is solely the client’s /
individual’s responsibility and Nicole Bourn, will not be liable. Nicole Bourn, provides nutrition consulting and recommendations only and is not licensed
to diagnose a medical condition or illness. The client / individual must consult a physician for any medical advice.
Waiver and Covenant Not to Sue
I have volunteered to participate in a wellness program and possible follow-ups under the direction of Nicole Bourn, which will include, but may not be limited
to nutritional planning. In consideration of Nicole Bourn agreement to assist me, I do here and forever release and discharge and hereby hold harmles
Nicole Bourn and his/her respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of
action, present or future, arising out of or connected with my participation in any nutrition program including any injuries resulting there from.
Assumption of Risk
I recognize that specific foods may create allergic and possible fatal reactions, most specifically, products containing nuts.
I have therefore specified any food allergies/ sensitivities I am aware of on the "diet profile" form. I am aware that specific foods may interact with certain medications.
I have discussed the side effects of all of my medications with my doctor or pharmacist. I also understand the wellness information I receive will not take my
medications into consideration unless I choose to list my medications on the "diet profile" form. If I am pregnant or lactating, have high cholesterol, high blood pressure,
high blood sugar, diabetes, renal disease, gastric by-pass surgery or any other medical condition that requires special dietary restrictions,
I must receive permission from my physician before participating in the wellness program, or may
be advised to seek help from another health professional.
I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this wellness program.
I understand that results are individual and may vary.