, I specifically authorize Holistic Wellness Alternatives to perform a
health evaluation and systems analysis and to develop a natural, integrative health improvement
program for me which may include dietary guidelines, herbal and nutritional supplements, energetic
balancing and holistic healing modalities, etc. in order to assist me in improving my health, and not
for the diagnosis, treatment or "cure" of any disease.
I understand that Holistic Wellness Alternatives uses a form of Autonomic Reflex Analysis
(also known as Applied Kinesiology) which is a safe, non-invasive, natural method of analyzing the
body's physical, emotional and nutritional needs. I understand that this is a means by which the
body's natural reflexes can be used to identify possible nutritional and energetic imbalances so that
safe, natural programs can be developed for the purpose of bringing about a more optimal state of
I understand that the methods used by Holistic Wellness Alternatives are not a means of
"diagnosing" or "treating" any disease including conditions of cancer, AIDS, infections, nor any other
medical condition, and that medical conditions are not being tested for or treated in any manner.
No promise or guarantee has been made by Holistic Wellness Alternatives regarding the
results of their testing methods, nor have any promises or guarantees been made about any of the
natural health, nutritional, dietary or energy balancing programs recommended by them. I
understand that the practitioners in this office are not medical doctors, but are nutritional
consultants and holistic wellness coaches.
This Permission Form applies to all subsequent office visits, Distance Healing Sessions and
consultations provided by Holistic Wellness Alternatives and its Practitioners and staff members.