Consent and Disclosure Form
Please read the following and provide your name and signature below as appropriate:
1. Nikki Moses and Kristina Law are not licensed physicians.
2. The treatment being provided by them and Moses Nutrition, Inc. is alternative or complementary to healing arts services licensed by the state of California.
3. The services to be provided are not licensed by the state.
4. The services provided may involve:
A. Nutritional balancing based on a hair mineral analysis (a lab-based screening test performed on body hair which shows amounts of 20 different minerals in the hair),
B. various forms of muscle testing, including Nutrition Response Testing, and
C. possibly other non-invasive forms of testing and stress-reduction techniques.
D. Dietary supplements may be recommended as well as diet suggestions, detoxification procedures and lifestyle recommendations.
5. All testing, techniques and supplements are recommended/provided for the purpose of reducing stress and balancing body chemistry. The theory is that by identifying possible areas of stress and nutritional deficiency through hair mineral analysis and/or other testing mentioned above, one can then provide needed nutrients to reduce stress and balance the body chemistry. None of the services or products recommended or provided by Moses Nutrition, Inc. or Nikki Moses or Kristina Law is intended as diagnosis, prevention, treatment or prescription for any condition or disease.
6. Nikki Moses and Kristina Law have diplomas in Nutritional Balancing Science as provided by Westbrook University of Wierton, West Virginia, and taught by Dr. Lawrence Wilson of Prescott, Arizona. Nikki Moses and Kristina Law are also trained in various other techniques such as Nutrition Response Testing and Morphogenic Field Technique as provided by those various independent training entities. Nikki Moses and Kristina Law work as nutritional consultants only.
By signing below, I acknowledge that I have read and understood the information above, and I request that Nikki Moses and Kristina Law (Moses Nutrition, Inc.) perform the above services to set up a program for the purpose of enhancing my health or that of a minor under my care. I authorize Nikki Moses, Kristina Law and Moses Nutrition, Inc. to forward the hair sample (if given) and personal information to Analytical Research Labs of Phoenix, Arizona for a hair mineral analysis and to share this personal information, analysis and/or other testing results with any other health practitioner deemed necessary by Nikki or Kristina solely for the purpose of designing a nutritional program (this is rare but can occur, especially if requested by the client).