To: __________________________
(name of client)

Welcome to my practice. As you know, I am a practitioner of Personal Metabolic Nutrition (PMN). I am not a licensed physician, nor is PMN service licensed by the state. The idea behind PMN is that:

All individuals do not have the same metabolic type. There is a test process developed by Dr. Kristal that can be administered that will determine your metabolic type. Once your metabolic type is known it is possible to design a diet that will balance your blood's ph (acid/alkaline balance) so that your metabolism is optimized. When your metabolism is optimized your body will spontaneously start to heal itself of many of its chronic ailments and achieve a healthier weight.

As a practitioner of PMN, I will provide you with the followings kinds of services:

I will provide you with a personal metabolic nutritional test kit that you can self-administer at home. I will analyze the results, determine your metabolic type and advise you on the best program of diet and supplements for your metabolic type. After 30 days you will retest again with the same kit and we will assess the success of the nutrition program.

I have been practicing PMN since 2003. My training and education is described below:

* Dr Kristal's Personal Metabolic Nutrition seminar for health practitioners.

In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy. I will keep the original in my records for at least three years.

My method of treatment, PMN, is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services, subject to requirements and restrictions that are described fully below.

If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving PMN treatment.

CALIFORNIA SENATE BILL SB-577

WHAT IT MEANS FOR PATIENTS

California Senate Bill SB-577, which was signed by the governor in September 2002, has profound implications for the practice of alternative forms of health care in California. SB-577 enables alternative and complementary health care practitioners to provide and advertise their services legally. However, they must also comply with certain requirements specified within the bill.

What does Senate Bill SB-577 mean for you, the patient?

SB-577 gives you access to alternative and complementary health care practitioners. You must be given information about the nature of treatment and the practitioner’s qualifications. Feel free to ask a practitioner any question you might have about your treatment. Check to see if your practitioner has been certified by a professional membership society. In addition, tell your doctor about any alternative treatment you are pursuing. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health care needs.

SB-577 helps to protect you. SB-577 requires unlicensed alternative health care practitioners to follow certain guidelines and restrictions.

Here are the things that unlicensed alternative practitioners are NOT allowed to do:

•  Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
•  Use X-ray radiation.
•  Prescribe prescription drugs, or recommending that you discontinue drugs that were prescribed by a licensed physician.
•  Set fractures.
•  Treat wounds with electrotherapy.
•  Put you at risk of great bodily harm, serious physical or mental illness, or death.
•  Imply in any way that they are licensed physicians.

In addition, an unlicensed alternative practitioner MUST DO the following things:

• Provide you with a statement, written in plain language that includes the following information: (1) that they are not a licensed physician and that their services are not licensed by the state; (2) a brief and clear description of the kind of services they provide and the reasoning behind it; and (3) a description of their education, training, and experience.
• Ask you to sign an acknowledgement that you received the above written statement, and provide you with a copy of it. They must also keep a copy of your signed acknowledgement for three years.

Acknowledgement and Consent to Receive Services:

I have read and understand the above disclosure about the PMN treatment offered by Roger Barr and Roger Barr’s training and education. I have discussed with Roger Barr the nature of the services to be provided. I understand that Roger Barr is not a licensed physician and that PMN services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Roger Barr, and agree to be personally responsible for the fees of Roger Barr in connection with the services provided to me.

Signed: ___________________________ Date: _________________________
(client/parent/conservator/guardian)

Indicate capacity to sign if other than client ________________________
(Parent to sign for child)

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