Liability for Nutrition Services: This form is an important legal document. It explains the risks you are assuming in beginning a holistic nutrition program. It is critical that you read and understand it completely. After you have done so, click "Submit" which will act as an assent to the terms as of the date submitted. Nutrition Disclaimer: The nutrition advice given by “SIMONE MAMAN” (which hereafter refers to: Simone Maman, FNS, EPC, is solely based on the information provided by the client/individual. The nutrition information given is meant only for the client/individual completing this nutrition questionnaire form. It is the sole responsibility of the client/individual to provide complete and accurate information. “SIMONE MAMAN” will not be liable for the effects of a nutrition assessment and/or advice based on any misrepresentation, misinformation, inaccuracy, or omitted information “SIMONE MAMAN” provides nutrition counselling and is not licensed to prevent, diagnose, alleviate or treat any medical conditions, disease, physical or mental ailments or pain or infirmities. Nutrition Waiver and Covenant Not to Sue: I (client) have volunteered to participate in a nutrition program under the direction of “SIMONE MAMAN” which will include, but may not be limited to nutrition and lifestyle coaching. In consideration of “SIMONE MAMAN'S” agreement to assist me, I do here and forever release and discharge and hereby hold harmless “SIMONE MAMAN,” 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 or lifestyle coaching including any injuries resulting there from. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary. Nutrition Assumption of Risk: I recognize that specific foods may create allergic and possible fatal reactions, most specifically, products containing nuts. I have therefore specified any food allergies/sensitivities I am aware of. I am aware that specific foods may interact with certain medications. I have discussed such food reactions and the side affects of all of my medications with my doctor or pharmacist and do not hold “SIMONE MAMAN” responsible for food and medication reactions. I also understand the eating plan I receive will not take my medications into consideration. If I am on medication, I am responsible for consulting with my doctor before starting a new diet plan. If I am pregnant or lactating, have high cholesterol, high blood pressure, high blood sugar, diabetes, renal disease, gastric bypass surgery, a family history of gout or any other medical condition that requires special dietary restrictions, I must receive permission from my physician before participating in the specific nutrition program designed for my use, or may be advised to seek help from another health professional.