*** Please Read Carefully *** I understand that Dr. Renee Rossi is not licensed in the Vermont to diagnose or treat medical conditions. She may be able to help in my management of my health, and may recommend various things for me to consider in management of my health and energy. She may assist me to learn the differences between medical diseases and the balancing of life energy, which deals with health factors that are within my own control. I may elect to consult a physician prior to seeing Renee Rossi and work with a physician concurrently, or I may decide that my concern about medical conditions does not call for seeing a physician at this time. I understand that I am seeking an educational experience rather than a personal diagnosis of any disease or malady. This educational experience is being provided as part of the teaching of the principles of Ayurvedic medicine. The educational experience may involve an examination of me and a demonstration of how Ayurvedic practices are used. In this experience, I may learn of conditions which would be part of an Ayurvedic diagnosis and may hear of the remedies that an Ayurvedic physician would use to treat these conditions. I am aware that people may develop pathological conditions (i.e., illness, injury and/or disease) when natural resistance or immunities may be lowered as result of energy and health imbalances persisting for extended periods. However, I am aware that an energy or health imbalance does not necessarily create or reveal the existence of a medical condition. I am aware that recovery from an illness or injury may be facilitated by balancing vital energy, but I am also aware that there may be no way to assure that this effect may occur in any particular case. I certify that I am not seeing Dr. Rossi for treatment of any physical infirmity or chronic ailment or injury, and that I am seeing them to help manage and strengthen my general health and vital energy. ImmuniTree practitioners do not recommend the discontinuance of legend drugs or controlled substances prescribed by an appropriately licensed practitioner. I acknowledge that I have voluntarily requested a consultation with Dr. Rossi and ImmuniTree practitioners. In consideration of my consultation with Dr. Rossi, I agree that I (or my heirs, guardians, legal representatives and assigns) will not make a claim or file an action against ImmuniTree or Dr. Rossi for injury for damage resulting from negligence or other acts, howsoever caused in connection with my consultation with ImmuniTree or Dr. Rossi. If I am the parent of a minor who I am asking ImmuniTree practitioners to consult with, I agree to indemnify and hold harmless Dr. Rossi or ImmuniTree practitioners, from claims or actions made or brought on behalf of my child in connection with MMI Faculty and Staff and Student Intern consultation. In addition, I hereby waive, release and discharge Dr. Rossi and ImmuniTree practitioners and its affiliated organizations from all actions, claims or demands I, my heirs, guardians, legal representatives or assigns, now have, or may hereafter have for injury or damages resulting from my participation in my consultation with ImmuniTree practitioners.