ChiroThin Medical Waiver Form

ChiroThin 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 ChiroThin Nutraceuticals. 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 any health related problems that arise by following the ChiroThin protocol.  Our products do NOT contain alcohol (people with alcohol sensitivities CAN use these products.)  ChiroThin is non-hormonal and can be used by children and teens.

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 ChiroThin, or in any way through your participation in the ChiroThin 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   Email:____________________________________________

(will be used for correspondence with the doctor only)