Iridology Analysis & Holistic Counselling Services

Wanda Rodrigues 519.322.9637

Wrodrigues01@hotmail.com

Client Personal Profile and Release Form

Please read carefully. If you agree, please sign and complete where indicated.
I,______________________________________________________________ have come to Wanda Rodrigues for Iris Fiber
Analysis, nutrition information and/or advice/counselling services as it may assist me in maintaining
optimum health. The services provided by Wanda Rodrigues are at all times restricted to consultation for
general nutritional health and well-being and do not involve diagnosing, prognosticating, treatment or
prescribing of remedies to the treatment of disease, or any act which will constitute the practice of medicine
in the province in which a license is required.
The analysis that I will be receive is in relation to Iridology only, and is not viewed as diagnosis of disease.
It is an attempt only to isolate inflammation or hypo activity and to make nutritional and lifestyle
recommendations to alleviate these discomforts. In all cases of disease, it has been recommended that I
consult with a qualified physician and or family doctor.
I hereby attest to the following:
I wish to state that I am fully knowledgeable in the fact that Wanda Rodrigues is not a Medical Doctor,
Doctor of Optometry or Doctor of Chiropractic, nor makes such claims to these and other medical professions.
I am fully aware and knowledgeable that Wanda Rodrigues has not, does not or will not attempt to treat,
prevent, cure or relieve a human disease, ailment, defect, complaint or other condition, whether physical or
mental by attendance or device or by a diagnostic test or other means, or offer, undertake, attempt to do, or
hold oneself out as able to do any of these acts.
I know that Wanda Rodrigues is a Natural Health Consultant and Holistic Counsellor and is proficient in
Iridology Analysis. Her sole purpose is to educate through discussions, lectures and tutoring as to the
historical uses of foods, minerals, supplements and herbs as well as exercise and positive lifestyle choices.
I acknowledge that I have read and understand all of the above statements and will not hold Wanda
Rodrigues liable, responsible or accountable for/to in relation to the status and condition of my health and
well- being, be it physically, mentally or emotionally.
I am here on this and subsequent visits solely on my behalf and not as an agent for any federal, provincial
or municipality agency on a mission of entrapment or investigation.
I do not object to giving any information that would be pertinent to this analysis.
I agree with all of the above statements by my signature.

______________________________________________ _____________________________________________
Please print your name
Signature

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Date

Iridology Analysis & Holistic Counselling Services

Wanda Rodrigues 519.322.9637

wrodrigues01@hotmail.com
Please answer the following questions as fully and completely as possible.
Please print or write clearly. Thank you!

Full Name: ____________________________________________________________________________________________________

Address:
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House number, P.O Box and street

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Town/City/Province/State/Country

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Postal/Zip Code

Phone Number including area code:

Home: ____________________________________ Cell: _______________________________ other:_____________________
Age: _______ D/O.B._________________________________ ________ _________ Sex: Male___ Female___ Other____
Month

Height: ______________________

Day

Year

please check one

Weight: ___________________

Health Concerns:
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Surgeries:_____________________________________________________________________________________
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Iridology Analysis & Holistic Counselling Services

Wanda Rodrigues 519.322.9637

Wrodrigues01@hotmail.com
Please answer the following questions as fully and completely as possible.
Please print or write clearly. Thank you!

Current Medications and Supplements:

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Family History of Disease/Illness (include grandparents for both mother and father)
Mother:________________________________________________________________________________________
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Father:_________________________________________________________________________________________
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Current and past 5 year history of your Occupations and Environments:
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Additional information or comments you would like to share:
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Iridology Analysis & Holistic Counselling Services

Wanda Rodrigues 519.322.9637

Wrodrigues01@hotmail.com

Client Notes/Comments
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