Waiver Form

Please read each statement below and type your full name stating you acknowledge and agree to each. When complete, please sign your name at the bottom then submit form.

By voluntarily participating in Blair Complex Care's services, I acknowledge the potential existence of inherent risks within the program. I explicitly accept these risks and take full responsibility for mine or my child's life, well-being, and all decisions made prior to, during, and following the utilization of these services.

I understand that the information provided at or in conjunction with Blair Complex Care services, including dietary recommendations and/or supplement advice is not intended to be a substitute for professional medical advice, diagnosis or treatment that can be provided by a physician, therapist, licensed dietitian or nutritionist, or any other licensed or registered health care professional.

I understand that Preston Brooks of Blair Complex Care is not a medical or mental health care provider and is not providing health care, medical or nutrition therapy services or attempting to diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. Rather, we are serving only in our capacity as educator, mentor and guide

I agree to seek the advice of my doctor or child's physician prior to and during services regarding any questions or concerns I have about my specific medical health situation. I agree to not disregard professional medical advice or delay seeking professional advice or start/stop taking any medications without speaking to my pediatrician, physician or health care professional.

I agree to disclose to Blair Complex Care in advance of any known or suspected food allergies or sensitivities, or any other health or mental condition that may be affected during the treatment program. If I suspect that me or my child is having a medical problem, I agree to inform Blair Complex Care immediately.

I understand that no claim is made as to the certain efficacy of any nutritional or supplement protocols. I understand that adopting any of these recommendations to implement for me or my child is voluntary and by choice.

If I choose to engage in Diagnostics, I voluntary consent to such testing and I fully understand and agree that Blair Complex Care is not acting as a medical practitioner or providing medical therapy services. I understand and agree that lab testing results and recommendations are not attempting to diagnose or treat. I understand that the labs are shared with me are purely educational.

Any information that is obtained from my medical history, treatment plans and coaching services will be treated as privileged and confidential and will not be released or revealed to any person other than my healthcare providers without my expressed written consent.

In rare likelyhood that me or my child becomes ill as a result of my participation in these services, I hereby release, discharge, and waive any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands which I have ever had, now have, and could have in the future against Preston Brooks and/or Blair Complex Care.

I have carefully read this document and by signing below I consent to all parts of it. I understand that by signing this release, I voluntarily agree to certain legal rights.

Thanks for submitting!