PERMISSION & AUTHORIZATION FORM
REGARDING THE USE OF
NUTRITION RESPONSE TESTING
PLEASE READ BEFORE SIGNING:
I specifically authorize the Natural Health Practitioner, Merry Matukonis RN, ACN, CCWFN
To perform a Nutrition Response Health analysis and to develop a natural complementary health improvement program for me which may include dietary guidelines, nutritional supplements, etc. In order to assist me in improving my health, AND NOT FOR THE TREATMENT, OR CURE, OF ANY DISEASE.
I understand that NUTRITION RESPONSE TESTING IS A SAFE, NON-INVASIVE, NATURAL METHOD, of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalances in these areas could cause or contribute to various health problems.
I understand the Nutrition Response Testing is not a method for “diagnosing” or “treating” of any disease including conditions of cancer, Aids, infections, or other medical conditions and that these are not being tested for or treated.
No promise or guarantee has been made regarding the results of Nutrition Response Testing or any natural health, nutritional or dietary programs recommended, but rather I understand the Nutrition Response Testing is a means by which the body’s natural reflexes can be used as an aid to determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health.
I have read and understand the foregoing.
This permission form applies to subsequent visits and consultations.