Client Information Form

All fields marked * are mandatory. Please enter NA if not applicable.

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CURRENT SITUATION
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CURRENT MEDICATIONS

PAST HISTORY
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FAMILY HISTORY
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DAILY SCHEDULE
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DAILY MEAL PLAN
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Nutrition & Wellness Coaching Consent form

I have gone through the Process, Legal & Medical Disclaimer, Payment Notice as well as the Cancellation Policy on the webpage above before registering for a program with Vinita Contractor.

I have given all the information pertaining to my health and have not hidden anything important from Vinita Contractor, Holistic Nutrition & Lifestyle Coach. During the consultation my present condition, its cause and how I can reverse or improve it will be explained to me. I will also be explained the nutrition regime that I shall have to follow to benefit from the consultation. I understand that this is a lifestyle that I will have to continue in order that my disease, once gone will not return. I understand that with this method I have to take responsibility for my health, and that regular lab reports may be necessary to be sure that the improvement is occurring and to enable reductions in medications.

I understand that I will be given a nutritional regimen and will be told what improvement I can expect. Following the nutritional regimen as prescribed is intrinsic to reversing / improving my condition. I do take full responsibility of my own health. I will also be suggested lifestyle changes. I understand that I should inform doctor if ever my health takes a turn for the worse. I understand that each individual and their disease is unique. I will not blame Vinita Contractor if I do not get cured of my disease or if I do not take professional medical advice where needed.

I agree to follow the recommended suggestions if I want to get the results through nutrition and lifestyle.