Disclaimer of Liability – Nutrition Consulting This form 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. After you have done so, please print your name, email address, and date in the spaces below. Disclaimer The nutrition advice given by Mary Davis is 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 _Mary Davis_ will not be liable. _Mary Davis _provides nutrition consulting and recommendations only and is not licensed to diagnose a medical condition or illness. Mary Davis is not a licensed nutritionist, and the information that she provides is based upon her personal knowledge and education. Waiver and Covenant Not to Sue I have volunteered to participate in a wellness program and possible follow-ups under the direction of _Mary Davis_, which will include, but may not be limited to nutritional planning. In consideration of Mary Davis_ agreement to assist me, I do here and forever release and discharge and hereby hold harmless Mary Davis and 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. I have therefore specified any food allergies/ sensitivities I am aware of when I met with Mary Davis for the initial consultation. 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. 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.