📞 (586) 747-4578
🕒 Mon-Fri: 09:00 AM - 5:00 PM | Sat & Sun: Closed

Consultation Form

Please fill out this comprehensive form to help us better understand your health needs.

Personal Information

Please specify the source that led you to us
This field is required
First name is required
Last name is required
Street address is required
City is required
State/Province is required
ZIP/Postal Code is required
Country is required
Gender is required
Date of birth is required
Please include units (lbs, kg, etc.)
Weight is required
Please include units
Height is required
Phone number is required
Valid email is required
Please provide the name and phone number of your emergency contact
Emergency contact is required

Health & Lifestyle Information

Dietary Information

Select all that apply
Select all that apply

Medications & Supplements

Acknowledgments & Disclaimers

Client Agreement & Informed Consent

Please read each section carefully and enter your initials to acknowledge your understanding and agreement.

Purpose of Natural Treatments

The Client, now referred to as "Client," acknowledges that the natural treatments provided by "The Pure Rx," now referred to as "Provider," are intended to assist in the management of health concerns.

Non-replacement of Medical Treatments

Client understands and agrees that the supplements offered by Provider, including GCMAF and Immunotherapy, are not a substitute for any ongoing medical treatments. Provider strongly recommends that Client consult their healthcare provider regarding any existing medical treatments for their health concerns.

Nature of Supplements

The Client further understands and acknowledges that supplements and any alternative treatment offered by "The PureRX" do not constitute cures for medical conditions, illnesses, or injuries. They are provided solely to alleviate symptoms.

No Guarantees

Client acknowledges that Provider does not guarantee any specific benefits or results from using natural treatments. The effectiveness of these treatments may vary from person to person.

Limited Liability

Client acknowledges that Provider shall not be held liable for any missed or unsuccessful medical diagnoses, treatments, or care related to any illness, disorder, disease, or condition that Client may be experiencing during treatment.

Legal Counsel

The Client understands the importance of seeking independent legal counsel to review and explain the terms of this agreement before proceeding.

Indemnification & Hold Harmless Agreement

This contract complies with your jurisdiction's relevant laws and regulations. Client agrees to indemnify and hold harmless stockholders, assigns, successors, and affiliates (Indemnified Parties) from, against, and in respect of all liabilities, losses, claims, damages, judgments, settlement payments, deficiencies, penalties, fines, interest, and costs, expenses suffered, sustained, incurred, or paid by the indemnified parties in connection with, results from or arising out of, directly or indirectly, Mathew Jadan, medical providers employed by "The PureRX" rendering medical care, services, advice, and treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, of "The PureRX or Mathew Jadan; Harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by "The PureRX or Mathew Jadan.

Risk Acknowledgment & Treatment Consent

I know the potential side effects of the above treatments, accept all the risks of taking the alternative medicine and medication, and will not seek indemnification or damages from the indemnified parties. I agree to administer hormone replacement therapy, nutritional supplements, and drugs designed to alter hormone levels, which will meet my specific symptom management treatment objectives without treating any diagnoses I might have.

By signing below, the Client acknowledges that they have read and understood this agreement and agree to its terms.

Electronic Signature *

Please provide your electronic signature below to confirm your agreement to all terms above.

Sign using mouse or touch screen