INFORMED CONSENT STATEMENT - Creating a Healthy You, Winter 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 class participants or wellness counseling client sessions.
CLIENT
I, , agree to work with Michelle Lentz, Holistic Nutrition Consultant for 28-days of nutrition counselling, on the Creating a Healthy You-Winter Challenge. My commitment is to do an initial weigh in by emailing a picture of my feet on the scale the Sunday prior to starting and each Sunday until the end of the challenge, check in daily with the Facebook support page, do 30 min daily workouts, 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 will not SHARE, COPY, FORWARD or RECREATE this program in any form unless I have written permission from Michelle Lentz.
The cost of my program will be $120.00 plus GST. Nutrition Counselling provided by Michelle Lentz, Holistic Nutrition Consultant. By completing and submitting 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:
** required fields