CONSENT, DISCLOSURE AND DISCLAIMER FORM
I request that Dr. Zakaria Kouloughli, Doctor of Naturopathy perform urine/saliva test, health evaluation, bio-electric therapy; and set up a program for the purpose of enhancing health and improving well-being.
I understand that Dr. Zakaria Kouloughli has a Doctorate Degree from Trinity School of Natural Health; an accredited school and recognized by the American Natural Wellness Practitioners Board in Sarasota, Florida (www.aanwp.org/anwpb), American Naturopathic Medical Accreditation Board in Las Vegas, Nevada (www.anmab.org), and the American Association of Drugless Practitioners in Galveston, Texas (www.aadp.net).
I understand that Bio-Electric therapy is not intended as diagnosis, treatment, prescription, or cure of any condition, mental or physical, real, or imaginary, and that it is not a substitute for regular medical care.
Signed (by client)________________________ date: ____________________
CLIENT'S NINTH AMENDMENT DECLARATION
ARTICLE IX, U.S. CONSTITUTION
"The enumeration in the constitution, of certain rights, shall not be construed to deny or disparage others retained by the people."
Under the Ninth Amendment to the Constitution of the United States of America, I retain the right to freedom of choice in health care. This included the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy or product recommended by the therapist, doctor, or any practitioner of my choice.
The enumeration in this declaration of these rights shall not be construed to deny or disparage other rights retained by me, or my right to amed this declaration at any time.
Notice is hereby given to any person who received a copy of this declaration and who, acting under the color of law, intentionally interferes with the free exercise of the rights retained by me under the Ninth Amendment, as enumerated in this constitutional rights, Title 42, U.S.C. 1983 et seq. Title 18, Section 241.
The client must read, sign, and date the following forms prior to receiving any service from Dr. Zakaria Kouloughli, ND
Feel free to copy and sign a copy; then email it to firstname.lastname@example.org