I hereby acknowledge and agree:



1. The purpose of nutritional counselling is to improve the overall health, vitality and well-being of the body through nutritional education and the use of natural foods and non-medicinal nutritional supplements. The Functional Nutritional Therapy Practitioner, Alexandra Radway, does not diagnose diseases, disorders or conditions.



2. The Functional Nutritional Therapy Practitioner, Alexandra Radway, is not a licensed Dietitian, Naturopathic Doctor or Medical Physician.



3. As part of the Nutritional Counselling Services, I may be asked to provide information concerning my physical habits, medical history, moods, energy levels, likes and dislikes, lifestyle and diet. This information is collected to enable the Functional Nutritional Therapy Practitioner to: (i) assess my knowledge of nutrition, (ii) education me about the benefits of sound nutritional practices and (iii) recommend dietary changes to improve my general health, vitality and overall

well-being. The Functional Nutritional Therapy Practitioner, Alexandra Radway will hold this information in confidence and will not release or disclose this information to any other person, without my prior consent, except as required by applicable law.



4. If the Functional Nutritional Therapy Practitioner, Alexandra Radway, suspects the existence of disease, disorder or condition, I will be informed of this suspicion. However, I acknowledge this is not a diagnosis or conclusion about the state of my health and that I am directed to promptly consult a licensed Physician or Naturopath about any suspected problems.



5. Should I request the Functional Nutritional Therapy Practitioner, Alexandra Radway, to recommend dietary changes and/or nutritional supplements to enhance my body’s natural ability to resist and/or overcome a known disease, disorder or condition, it is my responsibility to disclose the nature of the disease, disorder or condition and all other relevant details to the Functional Nutritional Therapy Practitioner, Alexandra Radway. If I have not previously consulted a licensed Physician or Naturopath about this disease, disorder or condition, I acknowledge that I am directed to promptly do so. I am not to alter or discontinue treatments prescribed by a licensed Naturopath, Physician or other licensed health professional without consulting the individual who prescribed the treatment.



6. In providing Nutrition Counselling Services to me, the Functional Nutritional Therapy Practitioner, Alexandra Radway, is relying upon the truth, accuracy and completeness of all information I have provided to her. Any recommendations I follow for changes in diet, including the use of nutritional supplements, are entirely my responsibility.



7. Alexandra Radway is in no way liable for my health or safety.



8. In consideration of my participation in the Nutritional Counselling Services, I hereby accept all risk to my health, including injury or death that may result from such participation and I hereby release the Functional Nutritional Therapy Practitioner, Alexandra Radway, on my behalf and on behalf of my personal representatives, estate, heirs, next of kin, and assigns from any and all costs, claims, causes of action and damages arising from any and all illness or injury to my person, including my death, that may result from or occur as a result of my participation in the Nutrition Counselling Services, whether caused by negligence or otherwise.



9. I understand that any therapies I undertake at Alexandra Radway Nutrition are undertaken of my own free will. I accept that the ultimate responsibility for my health care is my own and that Alexandra Radway Nutrition is here to support me in this. I understand that my practitioner reserves the right to determine which cases fall outside their scope of practice, in which event an appropriate referral will be recommended. I hereby agree to assume full responsibility for any manner of loss, injury, claim or damage whatsoever, known or unknown, incurred as a result of same and I, my heirs, executors, administrators or assigns for any loss, injury, claim or damage sustained as a result of my attendance and/or participation. I have read the above release and waiver of liability, and fully understand its contents and voluntarily agree to the terms and conditions stated.