Revive Healthy Nutritional and Social Health Ministry of Virginia

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Biological Terrain Live Blood Cell Microscopy

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Revive Healthy Nutritional Consultation Questionnaire

Gender*
I understand that the Revive Healthy Nutritional Practitioner/Consultant is not a medical doctor and can not diagnose, prescribe, treat, or make any claims to cure and disease or aliment. I consent to participating with the Educational Biological Terrain Live/Dry Blood Cell Microscopy research, along with alkaline water / nutritionals information presented or available. I understand I am responsible for my own health choices (and/or choices of my children). Therefore, I release Revive Healthy Nutritional and Social Healthy Ministry of Virginia, its employees, offices, owners, and representatives from any past, present or future health related issues which may occur. By signing this questionnaire form, I hereby consent to a Revive Healthy Nutritional Practitioner/Consultant the use of a lancet to retrieve a sample (s) of my blood, urine or saliva; and the release of my information gathered from the consultation and sample (s) to be used for education and/or research findings.*
Are You Taking Blood Thinners Either Herbal of Pharm?*
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