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Name:________________________________Gender:______________________Weight:_____________________
Address:__________________________________________________________Date:_________________________
NOTE:
The underlying principle of this analysis is based in REFLEXOLOGY and ACCUPUNCTURE points.
This is only and ANALYSIS not DIAGNOSIS. It is up for the clients perception whether they will accept or not the
result of this analysis. Our intention is to make everyone aware regarding HIS/HER health through our nutritional
counseling program. For this reason is not liable to any untoward effect of this analysis.
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Client Signature
ADVICES: (NO ICE COLD WATER)