REQUEST AND AUTHORIZATION FORM
I have hired and authorize Dr. Al Aguirre to comply with my request for
any one or more of the following: information on health products, herbs and
their use, nutritional consulting, recommendations, assessments, tests and/or
treatment(s), regime(s) or modality(s) as regards health-related services which
are more particularly described as follows:
Invasive and non-invasive procedures known
as blood chemistry analysis, toxic metal screens, with proper collection
techniques as well as herbal and nutritional counseling or any other
recommendations for the prevention of disease and the maintenance of natural
health.
I
request and authorize these health-related services as a right to Freedom of
Choice in Medicine and Health Care, retained by me as an American or United
States Citizen and in any state I reside in, under the Ninth Amendment to the
Constitution for the United States of America.
I will consult another doctor or professional of my choosing if I feel
a second opinion is necessary, if I have not already done so. If I am a guardian or parent of a minor, I
will seek a second opinion from another doctor or professional of my choosing
to confirm any recommendations made for the prevention of disease or for
improving the health of the minor.
Certain Rights Not Denied to the People
Section
1.1 The
enumeration in the Constitution, of certain rights, shall not be construed to
deny or disparage others retained by the people.
The
enumeration in this declaration of these rights shall not be construed to deny
or disparage other rights retained by me, or my right to amend this declaration
at any time.
I,
the undersigned, hereby retain the following natural and God-given rights under
the Ninth Amendment to the Constitution for the
1.
The right to seek any knowledge and any benefits of non-allopathic medicine,
counseling, information, recommendations, assessments, evaluations, tests
and/or treatment(s), regimen(s) or
modalities from any individual of my choice for any health reason.
2.
The right to select or reject any individual(s) as my personal nutritionist
(s), whether that individual is a medical doctor, herbalist, naturopath,
chiropractor, druggist, nurse, iridologist, medicine man, nutripath, colon
therapist, health food store clerk, sales person of health products,
minister,
priest, pastor,
preacher, relative, friend, dietician or anyone from the general citizenry who
is or is not licensed by the State I'm residing in or who has, or has not, any
known formal training or claimed knowledge, education, insights, or
qualifications, to answer any questions concerning method of health retention
or disease prevention.
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3. The right to Freedom of Choice in
Medicine and Health Care in its most liberal construction, including the rights
to choose my own diet, therapy, regimen, modality, drug, food, medicine, herb,
or health product for any health condition I have or may have as evaluated by
myself or by anyone of my choosing whether licensed by the State or not.
CONSTRUCTIVE NOTICE
Title 28
Unites States Code-Federal Criminal Code and Rules.
Crimes against the
people's Civil Rights.
Section
241. Conspiracy against rights of
citizens
If two or more persons conspire to injure,
oppress, threaten, or intimidate any citizen in the free exercise or enjoyment
of any right or privilege secured to him by the Constitution or laws of the
United States, or because of his having so exercised the same; or
If two or more persons go in disguise on the
highway, or on the premises of another, with the intent to prevent or hinder
his free exercise or enjoyment of any right or privilege so secured.
They
shall be fined not more than $10,000 or imprisoned not more than 10 years, or
both; and if death results, they shall be subject to imprisonment for any term
of years or for life.
I,
THE UNDERSIGNED REQUESTOR, DECLARE UNDER THE PENALTIES OF PERJURY THAT I AM NOT
AN AGENT OF, EMPLOYEE OF, OR AN INFORMANT FOR ANY AGENCY OF THE FEDERAL OR
STATE GOVERNMENTS.
I
have agreed to wave all my HIPPA rights in order to gain these requested
services with all disagreements and misunderstandings arbitrated by a neutral
party that our service picks.
I
have also agreed to pay all fees when services are rendered, unless prior
financial arrangements have been made. I have agreed to pay a 21-day trial
membership with a 60-day renewal for “Doctor’s Health Assurance Plan” as agreed
upon.
______________
________________________________________________________
Date Signature of Requestor/Responsible for
Payment
Print: Requestor's Name:
________________________________________________
Print
Information:
Address:
__________________________________ Phone: ________
City:
Fax: __________________ E-Mail:___________________________
Signature Witness:
1._______________________________Date:___________
Signature Witness:
2._______________________________Date:___________
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