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.
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.