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I acknowledge that I am aware that David V. Reta, owner of Reta’s Optimal Health & Aging (RO-HA) is not a medical doctor and does not diagnose disease.

I Agree

I also acknowledge that I have been warned that I should consult a Physician before undergoing any dietary or food supplement changes.

I Agree

 I also affirmatively state that I have disclosed any and all known medical or genetic conditions, medications I use, and any significant personal or family medical history. Any recommendations that I follow for changes in diet, including but not limited to the use of food supplements, are entirely my choice and my responsibility. I am knowingly assuming any risk associated with nutritional counseling.

I Agree

In consideration of my participation in nutrition counseling, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release David V. Reta, owner of Reta’s Optimal Health & Aging (RO-HA), from any liability whatsoever to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness, injury or other harm to my person, including my death, that may result from or occur during my participation in nutrition counseling, whether caused by the sole or concurrent negligence of David V. Reta, Reta’s Optimal Health & Aging (RO-HA).

I Agree

I further agree to indemnify and hold harmless David V. Reta, Owner of Reta’s Optimal Health & Aging (RO-HA), to the fullest extent permitted under law, from any and all liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described nutrition counseling program.

I Agree

I have carefully read this agreementand understand it to be a release of all claims and causes of action for my injury or death or damage to my property that occurs while participating in nutrion counseling and or death of any person and damage to property caused by my neglegent or intenetion acto or ommission. 

I Agree

TERMS AND AGREEMENTS

Auto-Payments: You hereby voluntarily agree to a monthly automatic-payment. On your behalf, you allow RISE Bodyworks to process an auto-payment every month, on the anniversary-day of the initial purchase. For example, if the initial purchase was on the 12th of a given month, auto-payments will process on the 12th of EVERY MONTH thereafter. Once your payment cycle day has been created, you cannot alter it. You must cancel your auto-payment and membership in person and sign a cancellation form. Cancellation Form must be signed and dated at least 30 days prior to the next recurring payment.

I Agree

Communication: You are required to maintain an active email address on record with Rise Bodyworks to ensure open communication regarding, but not limited to, emergencies, forces of nature, our schedule, operations and/or crucial updates. Additionally, please and agree to assign risebodyworks@gmail.com as an approved contact and stay subscribed to our emails for as long as you are a member. Rise Bodyworks will communicate with you via email and social media to ensure crucial updates are disseminated and received by our valued members, patients and clients. In the event of a national, global emergency/disaster we must have your current contact information.

I Agree

Refunds: You understand there are NO partial or full refunds, or account credits. All sales are final.

I Agree

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Intake

What do you hope to accomplish from this appointment? *

Do you currently take any vitamins or supplements? If yes, please list: *

Do you currently take any medications? If yes, please list: *

Please provide your height and current weight: *

What would you like to weigh? *

Do you smoke? If yes, how much? *
What is your family health history? Check all that apply: *
Heart Disease
Diabetes
Cancer
High Blood Pressure
High Cholesterol
Other

What is your health history? *

What questions do you have for the dietitian? *
Physical Activity

Do you currently exercise? *

How frequently do you exercise aerobically? *

What do you do for aerobic activity? *

How frequently do you strength train? *

What do you do for leisure activities? *

Do you have any exercise limitations? If yes, please describe: *
Dietary Habits
How would you rate your diet? *
Excellent
Good
Fair
Poor

Has your appetite changed within the past month? If yes, please explain: *

Do you have ay food allergies or food intolerances? If yes, please list: *

Have you ever been on a diet? If yes, what diets have you tried? *

Are you currently following a special diet (ex. low fat, low salt)? If yes, what diet are you on? *

Have you ever purposefully restricted food intake and obtained what you or others felt was an extremely low or unhealthy weight? If yes, please explain: *

Have you ever thrown up, used laxatives, fasted, or exercised for long periods of time to lose weight? If yes, please explain: *

Who prepares your meals? *

Where do you eat your meals? *

With whom do you eat your meals? *
What is a normal meal pattern for you? (Check all that apply) *
Breakfast
Mid‐morning snack
Lunch
Mid‐afternoon snack
Dinner
Evening snack

Please provide the usual time you eat for breakfast, lunch, dinner and snacks: *

Please list the foods you typically have for breakfast, lunch, dinner and snacks: *
How often do you eat fast food or go to a restaurant? *
0‐1 times/month
2‐3 times/month
1‐2 times/week
3‐4 times/week
5+ times/week

List the restaurants you eat at when dining out: *
Which of the following beverages do you drink regularly? (Check all that apply) *
Milk
Juice
Soda/pop
Coffee/tea
Water
Sports drinks
Other
How often do you drink alcohol? *
0‐1 times/month
2‐3 times/month
1‐2 times/week
3-4 times/week
5+ times/week

When you do drink, on average, how many servings of alcohol do you drink in one sitting (1 serving = 12oz. beer, 5 oz. wine, or 1 oz. liquor)? *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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