CONSENT TO SERVICES FORM

I have read and understand the following form and acknowledge that the

purposes, goals, techniques, procedures, limitations, potential risks and benefits

of service(s) to be performed have been explained to me. I have felt free to ask

my practitioner questions regarding the proposed services and have received

satisfactory explanations. I understand that I am free to discontinue service at

any time.

I hereby voluntarily consent to participating in herbal and/or nutrition

consultation(s) with Monica McCollin, MS, CNS, LDN, RYT Clinical

Herbalist, Licensed Nutritionist & Yoga Instructor.

Name

First Name

Last Name

Legal Guardian Name

(If under 18 years old.)

Address

Telephone

Message

Electronic Signature

Clicking this box serves as your electronic signature.

I accept the terms and understand that clicking this box serves as my electronic signature.

I do not accept the terms and do not wish to begin working with you.