Please read the following information very carefully. Once completed, please provide information in the boxes provided and click Submit. Thank you!
If you would like a hard copy of the form, you can download the pdf at the bottom of the page.
By purchasing wellness consultation services from Mariana MacDougall, MD (hereinafter referred to as “Coach”) and healthwithmariana.com website (hereinafter referred to as “Site”), I confirm that I have read and agreed to each of the following statements and that I wish to proceed:
- I understand that the coaching services I will be receiving from my Coach are not offered as a substitute for professional medical or mental health care and are not intended to diagnose, treat, or cure any medical or mental health conditions. I also understand that my Coach is not acting as a medical professional or a mental health counsellor.
- I understand and agree that I am fully responsible for my choices and decisions about the suggestions made.
- I understand that it is my responsibility to discuss any and all information provided during consultations with my primary health care provider or any other health care providers/specialists whose care I may be under before beginning anything suggested by my Coach.
- Due to HIPPA privacy regulations, my information will be held confidential and not shared with anyone for any reason.
- I understand that the use of technology is not always secure and I accept the risks of confidentiality in the use of email, text, phone, Skype, Zoom, WhatsApp and other technology.
- I hereby release, waive, acquit, and forever discharge my Coach, Mariana MacDougall, MD, MDLV Consulting, LLC., healthwithmariana.com, any agents, successors, assigns, personal representatives, executors, heirs and employees from any liability, every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have involving loss, damage or injury, of any nature whatsoever to my person, my family, or my estate, resulting in any way from, or connected with, or resulting from, the Coach’s suggestions, information contained on the Site, and/or suggested nutritional products and supplements arising out of acts or omissions by myself or by my Coach as a result of the suggestions given by my Coach or otherwise resulting from the consulting relationship contemplated by this agreement.
- I further declare and represent that no promise, inducement, or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.