Consent Form

Consent Form
(must be filled out and signed by doctor)

Please print your name and degree(s) as you would like it to appear on your reports.
Doctor's Name:________________________________________________
Clinic Name:__________________________________________________
Address:________________________________________________________________________
City:___________________________________ State:________ Zip:_______________________
Office Phone: (____)_________________________ Fax: (____)_______________________
Specialty: ____________________ E-mail ____________________________________________

Statement of Consent

I understand that the Nutrabalance recommendations made by computerized technology are meant to be solely educational to the patient, informational to me as the health care provider, and are not meant to diagnose or treat disease. I also understand that these recommendations are not designed to take the place of traditional methods of medical treatment. As the health care practitioner using these recommendations, I further consent that no guarantee has been offered in terms of a cure or the outcome from their use in the treatment of any patient.

Further I waive any claim against Nutrabalance which may arise by my using Nutrabalance recommendations in my practice.

I hereby agree to indemnify and hold harmless Nutrabalance for every claim and action which may be brought against myself, as a consequence of Nutrabalance supplying me with the Nutrabalance recommendations.

____________________________________________ __________________
Doctor's Signature Date

Supplement company preferences (Generic is always recommended as one option):

1. _______________________________________________________
2. _______________________________________________________
3. ___________________________________________

Send or fax this completed and signed form to:

Nutrabalance
4740 Table Mesa Drive, Suite B
Boulder, CO 80305
Phone: 800-468-7903
Fax: 720-304-6527
info@nutrabalance.com