Thank You and Welcome to Revised NuTRITION!

Below is our client information form.  It is important that you fill out the following form accurately as this information will be used to help develop your individualized nutrition program.

 

Please complete the form below

Name *
Name
How much weight do you want to lose?
Please provide the following girth measurements
Please provide the following girth measurement
Please provide the following girth measurement
Daily Activity *
How would you describe your normal daily activities?
Exercise Intensity *
How would you describe you level of exercise?
Exercise Regimen *
How many hours per week do you exercise?
Please list any physical activities you participate in outside of work or the gym.
Are you or could you be pregnant?
"NOTICE" "State law allows any person to provide nutritional advice or give advice concerning proper nutrition--which is the giving of advice as to the role of food and food ingredients, including dietary supplements. This state law does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is a licensed health practitioner to state that any product might cure any disease, disorder, or condition." This form is an important legal document. It explains the responsibilities you are assuming beginning Revised Nutrition Programming. It is critical that you read and understand both pages completely. After you have done so in the spaces provided, initial the first page then print your name, email address, and date and sign on the last page. Liability Waiver I certify that I am 18 years of age or older and have elected to participate in Revised Nutrition’s weight loss and health improvement program. I do here and forever release and discharge ad hereby hold harmless Ashley Miller, Brandy Buijten and Mindy Suffredini and their heirs, family members and property from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of my participation in the Revised Nutrition Programs. I acknowledge and agree that no warranties or representations have been made to me regarding results I will achieve from this program. I understand that results are individual and will vary. Furthermore, I hereby agree to indemnify, defend, and hold harmless Ashley Miller, Brandy Buijten and Mindy Suffredini and their heirs, family members and property from against any and all claims liability, loss, damage, expense, costs of any kind on account of injury to me or on account of my death or loss of or damage to property or other persons arising from activities I engage in as part of my participations in the program (including without limitation attorney fees, costs and expenses of any litigation, arbitration or other proceeding) Nutrition and Physical Assumption of Risk I recognize that specific foods may create allergic and possible fatal reactions, and it is my responsibility to know if I am allergic to any foods. I am aware and have been advised that I should consult my physician before using any dietary supplements, especially if I am pregnant, nursing or under medical supervision for any illness. I am aware that specific foods and supplements may interact with certain medications. It is my sole responsibility to discuss such food and supplement reactions and the side effects of all of my medications with a physician who is familiar with my medical history and the current state of my health I will not hold Ashley Miller, Brandy Buijten or Mindy Suffredini and their heirs, family members and property responsible for food and medication reaction if I fail to take this crucial step before starting this program. I clearly understand I MUST consult my physician about making any decisions pertaining to medications, medical treatments and dietary restrictions pertaining to any illness/medical treatment I am currently undergoing. Any information received by Ashley Miller, Brandy Buijten or Mindy Suffredini is for informational purposes only and is NOT MEDICAL ADVICE. Only a doctor, familiar with my personal medical history is qualified to give me medical advice. I am aware that it is my responsibility to know if I have any physical limitations to follow any of the suggested routines during the Program, and will need to modify them, if needed, to fit my physical needs or limitations. I certify that I have read and agree to this liability waiver: Cancellation Policy: A payment is required before you may take part in the program. We require a minimum of three months subscription and no refunds will be given for the three months period. Once this period has ended the client may choose to end their subscription for the following pay period. No refunds will be given once payment has been received. Sincerely, The Revised Nutrition Team
ESignature *
ESignature
Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Revised Nutrition.
Date *
Date