INFORMED CONSENT STATEMENT - Pre-Christmas Weight Loss Challenge
I, Michelle Lentz, am Holistic Nutrition Consultant. I provide health and wellness services to individuals and groups on health supporting foods and lifestyle practices to teach individuals to make good decisions to support their well-being.
I am NOT a Registered Dietitian or a Medical Doctor. As such, I do not provide medical nutrition services, or diagnose and treat disease. Rather, I educate people on the benefits of a healthy lifestyle to improve their quality of life. I advise people with existing medical problems to consult with medical doctors. I share evidenced-based health information, whether to challenge participants or wellness counseling client sessions.
CLIENT
I, agree to work with Michelle Lentz, Holistic Nutrition Consultant during the Pre-Christmas Weight Loss Challenge starting November 16, 2020. During the duration of this program my commitment is to do an initial weigh in by emailing a picture of my feet on my scale Monday, November 16th, 2020, prior to starting and each Monday until the end of the challenge, check in daily with the Facebook support page, do 30 min workouts daily, drink your water, and be dedicated to my health.
I understand that information provided on the relationship between nutrition and health is NOT meant to replace professional medical treatment for any health problem or condition. Health education and medical care are complementary and integrative when properly delivered.
I choose to improve my health by assuming greater self-responsibility to reduce or eliminate unhealthy behaviors that are contrary to my well-being.
I understand that I may not feel well during the challenge as my body detoxifies, adjusts to the new foods and calories. Some side effects may include: headache, bowel disturbances, fatigue, weakness, hunger and cravings.
I understand that this program is not designed for vegans or for individuals with a large amount of allergies that would be unable to fully follow the menu plans. In this case you would be best suited to do a customized nutrition program.
I will not SHARE, COPY, FORWARD or RECREATE this program in any form unless I have written permission from Michelle Lentz. This includes forwarding your weekly menu plans to others.
I understand that the Challenge is run as a group not on an individual basis. Questions are asked on Facebook. All weigh ins are confidential and sent in privately.
The cost of my program will be $120 plus GST for a 28-day Nutrition Challenge provided by Michelle Lentz, Holistic Nutrition Consultant. By completing and signing this form, I agree to be a client and to satisfy all above requirements.
I HAVE READ AND AGREE TO ALL.
Participant Name:   Date:  
Other Registration Information:
I have participated in a previous challenge with Michelle Lentz: if YES, Date:
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