I freely acknowledge that I am fully aware that Mark J. Brewer and his associates are not medical doctors, or any other kind of medical practitioners and they have not represented themselves in any way as possessing any medical expertise or medical training whatsoever and they have not prescribed, diagnosed or treated or recommend any particular treatment or medication or substance for me in respect of my injury, ailment or disease that I may possess.
I have not been cajoled, coerced, threatened or persuaded by Mark J. Brewer or his associates to undergo or partake in any particular treatment or medication or substance, and that I freely acknowledge that any unorthodox or unusual treatment or medication or substance that I may utilize is done with my full awareness and acknowledgement that it is of my own free will.
I, the undersigned, for myself, my heirs, successors, executors, administrators and assignees, hereby release and forever discharge Mark J. Brewer, his associates, their heirs, and his heirs, successors, executors, administrators and assignees, from any and all actions, causes of action, claims and demands for or by reason of any damage, loss or injury, to person and property which heretofore has been or hereafter maybe sustained in consequence of any medication, substance or treatment which I may use or consume in any respect of and for any attempts by myself or anyone on my behalf to cause temporary or permanent relief from the symptoms of any injury, ailment or disease with which I have been or will be diagnosed.
If you are in agreement with this disclaimer, please place your name and email address on the last box on the information form (Item #18).