HCG Medical Waiver Form

HCG Homeopathy Weight Loss Program
Medical Waiver and Release of Liability

New Life Chiropractic is not responsible for negligent use, or health related circumstances regarding the use of homeopathic HCG. It is your responsibility to check with your personal physician, primary care facilitator, or MD regarding the personal use of homeopathic HCG.  We, at New Life Chiropractic advise you to check with your personal physician before starting this or any weight reduction program.  New Life Chiropractic cannot be held responsible for lack of education regarding the use of homeopathic HCG. We encourage you to research the use of this homeopathic and its possible affects on your individual health.  If you have any concerns regarding the use of homeopathic HCG, we encourage that you seek the advice of your primary care physician. New Life Chiropractic acknowledges Dr. A.T.W. Simeon’s research in the use of HCG and recommends following his protocol as described by him in his original manuscript. New Life Chiropractic cannot be held responsible for any health related problems that arise by following Dr. Simeon’s protocol.

Dr. Simeon’s original manuscript outlines health concerns during the treatment and you are advised to research his material and address these concerns with your doctor.

People who should NOT take HCG: Anyone who is a recovering alcoholic (our tincture is an alcohol base), anyone with Heart Disease, or a diagnosis of cancer, or Hyperthyroidism, women with an ovarian cyst, those with Diabetes Type 1, or men with Testicular or Prostate Cancer. HCG can aggravate gout, and if you have gall bladder issues HCG can aggravate it because of the small fat intake.

By completing this form, you provide your signature, confirming that you agree to not hold New Life Chiropractic responsible for any health-related issues as a result of taking homeopathic HCG, or in any way through your participation in the HCG Weight Loss Program.

Print Name: ______________________________________________ Date: ___/___/___

Signature: _______________________________________________

Ship To

Address: ________________________________________________ Business or Residence?

City: _________________________ State: ____ Zip: ___________

Cell Phone: _______________________________________

Do you have texting ability on your cell phone: Yes No

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(will be used for correspondence with the doctor only)