Please read carefully before submitting:

I hereby authorize Gloria Gilbère and her representatives to act on my behalf concerning the corrective, non-drug programs offered to achieve health. I specifically authorize her to evaluate my health concerns/problems and to recommend the appropriate nutritional and detoxification programs, lifestyle and environmental modifications. I warrant that all information submitted for analysis and evaluation was submitted by me and is true to the best of my knowledge. I also attest that I am disclosing all medical information, name of my current physician and any drugs, herbs, supplements or substances I am currently, or have previously, consumed. I understand that Gloria is available to work with my medical doctor or health care provider to implement a program of integrative medicine and therapy. I hereby give permission to release my medical records and information pertaining to my medical and alternative therapies, to specific persons, only upon this office receiving authorization from me in writing and dated with specified name or names.

I recognize that the approach used will be non-medical. I also recognize that she will evaluate my condition so that she can have the information necessary to approach my problem and its causes, not just its symptoms. I, and any family members, heirs, or any other parties, hereby hold Gloria Gilbère. et al harmless in any way. I understand that the programs recommended in no way are taking the place of traditional medical treatment. The programs recommended are designed to allow the body to have the necessary natural means to promote health and healing and boost my body's immune system by natural and nutritional programs, alternative therapies, and lifestyle modification.

Client’s Name:   E-mail:  Date:

If client is minor, parent/guardian must acknowledge below:

Name of Minor:

Name of Parent/Guardian 

Click the button below to print this form, as you need to mail us a signed copy.
You should also print this as a backup and for your own personal records.