Consent * I agree to the statement below
By submitting this form, I am requesting a consultation to review a test from the list below from Mindy H. Pelz Chiropractic Corporation d/b/a “Family Life Wellness”. I understand that Dr. Mindy Pelz and Family Life Wellness are simply interpreting the test results that are supplied and manufactured by the third party listed below.
The Testing available for review are:
Company: Vibrant Wellness
Dutch Hormone Complete
Company: Precision Analytic
Doctors Data Heavy Metal Test
Company: Doctors Data
I understand and agree that the fee for these services is listed above and is payable upon purchase.
Terms & Conditions:
If accepted, I understand that the services provided by Dr. Mindy Pelz and her team do not create a practitioner-patient relationship; is purely educational and for informational purposes with Dr. Mindy Pelz, and members of her team acting as a health coach.
I understand that Family Life Wellness, Dr. Mindy Pelz, and her team does not dispense medical advice nor prescribe treatment. Rather, she provides education to enhance my knowledge of health as it relates to foods, fasting, dietary supplements, and behaviors associated with health. While nutritional and botanical support can be an important compliment to my medical care, I understand that health coaching is not a substitute for the diagnosis, treatment, or care of disease by a medical provider.
I understand that any testing provided by Family Life Wellness are third party services and that Dr. Mindy Pelz and her team are simply interpreting the results of the testing.
I also agree not rely on this information as a substitute for, nor a replacement of, professional medical advice, diagnosis, or treatment. If I have any concerns or questions about my health, I understand that I should always consult with a physician or other health-care professional. I will not disregard, avoid or delay obtaining medical or health related advice from my health-care professional because of this health coaching arrangement. The use of any information provided by Family Life Wellness, Dr. Mindy Pelz and/or her team is solely at my own risk.
Neither the services provided by Family Life Wellness and Dr. MIndy Pelz, nor any information provided to me is intended to suggest that I should not seek professional medical care, or that I should disregard professional medical advice. Nothing stated or made available through any services provided by Family Life Wellness are intended to be, and must not be taken to be, the practice of medicine or the provision of health care treatment, instructions, diagnosis, prognosis or advice.
If the client is under the care of a health care professional or currently uses prescription medicals, the Client should discuss any dietary changes or potential dietary supplements use with his or her doctor, and should not discontinue any prescription medications without first consulting his or her doctor.
Assumption of Risks and Releases:
I expressly assume the risks of the Deep Dive session, including the risks of trying new foods, the risks of trying new styles of fasting and/or diet variation, the risk of trying new supplements, and the risks inherent in making overall lifestyle changes.
I hereby release Family Life Wellness, Dr. Mindy Pelz, or her team from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has, or will have in the future against Family Life Wellness, arising from the Client's past or future participation in, or otherwise with respect to, consultation sessions.
In no event shall Family Life Wellness, its subsidiaries, employees, contractors be liable for lost profits or any special, incidental, consequential or multiplied damages arising out of or in connection with our services, or this agreement (HOWEVER ARISING, INCLUDING NEGLIGENCE), including, but not limited to, loss of profits, loss of use or other economic damages, even if advised of the possibility of such damages, or any failure to realize any specific benefit or health-related outcome. This limitation of liability will apply regardless of the form of action, whether in contract, tort or by statute. Family Life Wellness’s liability, and the liability of their subsidiaries, employees, contractors, suppliers, and manufacturers, to me or any third parties, in any circumstance, is limited to the greater of (a) the amount of the purchase or (b) one hundred ($100) dollars.
All sales are final and no refunds will be afforded and you waive any rights to charge-back your purchase with your credit card processor.
Arbitration and Governing Law:
It is understood that any dispute, that is as to whether any services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration by the American Arbitration Association in Alameda County, California, as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on a court of law before a jury, and instead are accepting the use of arbitration.
It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to service provided by Family Life Wellness including my spouse or heirs and any children, whether born or unborn, at the time of the occurrence giving rise to any claim.
Both parties shall be entitled to engage in all forms of discovery as permitted under California law. The prevailing party shall be entitled to recover the costs of arbitration unless otherwise determined by the arbitrator and shall be entitled to reasonable attorney’s fees as determined by the arbitrator.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement.
All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California provisions relating to arbitration.
My signature below indicates that I have read and fully understand all terms of this agreement, including my responsibilities and assumed risks