Terms of Service
Consent Form
Paragon Health Centre
TERMS OF SERVICE
CONSENT FORM
​
Name: ______________________________
(Ref: Health & Disabilities Act 2000, The Privacy Act 1993)
Epigenetic Hair Scanning
​
I acknowledge the following parameters of the Cell Wellbeing epigenetic hair scanning procedure:
​
* The Cell Wellbeing 90 day booster program provides recommendations on diet and supplements to optimise the condition of the body.
​
* A report will be produced as a result of epigenetic scanning techniques. This will identify areas of diet and vitamin/mineral excesses or deficiencies that affect the homeostasis of my body.
​
* The report will recommend an optimized diet and supplement regimen calculated to parallel the existing condition of my body.
​
* The primary goal of the program is to control calorie intake, protein and fibre levels and optimize health and well-being.
​
* To enhance this goal various vitamin and mineral will be recommended sourced from Metagenics, an Australian company which provides ‘practitioner only’ supplements.
​
* These supplements are more potent than Japanese counterparts and consequently are more effective for the 90 day ‘booster’ program.
​
* As they are more highly concentrated, (most of) the supplements recommended should be taken 5 days on 2 days off, to allow the body to assimilate the changes on a gradient.
* It is anticipated that after 90 days of strict adherence to the program, there will be an observable boost in your homeostasis.
​
* A second scan would then be advisable to fine-tune any further improvements.
​
Terms of Service
​
* The recommendations of this service are recommended by trained supplement advisors who have graduated with a JSADA diploma in Japan.
* For medical advice, medicinal prescriptions or diagnosis of medical conditions, please consult your own doctor.
​
* I have been advised that certain diets and supplements are not suitable if I am pregnant and I have advised my practitioner if I am pregnant.
​
* All procedures will be clearly explained during the consultation.
​
* I have the right to decline or withdraw my consent at any time.
​
* I understand that any records kept by Paragon Health Centre will only be released upon my permission, and that during these times my identity will be protected and privacy maintained.
* I have the right to see any information held by Paragon Health Centre.
​
* I have read, or had read to me, this consent document and I understand what has been explained to me, and have asked any questions I may have about its content.
​
* I understand and accept that failing to adhere to the diet and supplements recommended will minimise (or negate) the efficacy of the program.
​
* You can sign and return this document with your payment or alternatively tick the box 'Terms of Service' on your invoice to signify you have accepted the tems stated above.
​
Signature:
Name _______________________________
(BLOCK CAPITALS)
Signature: _________________________________
(Written consent from Guardian or Parent is needed before
accepting minors - 16 years and under)
Signature: _______________________________
(Custodial Parent / Legal Guardian)
Date: _______________________________
​
​