includesyouranalysis,apersonalizeddietbook,andanaudio-cassettetape
withyourpersonalcounselingrecordedonit.Succeedingconsultationsfol-
lowingtheinitialonearethirtydollars($30.00)each.Wedonotusethisser-
vicetodiagnoseorprescribe,buttoofferhealthinformationtohelpyoupro-
motealifestylethatleadstohealthand/orcooperatewithyourphysician.
When an application is made you will receive the following:
1. A nutritional questionnaire for you to complete.
2. An authorization form, signed by you giving us permission to per-
form this evaluation. Ifyou are under a medical doctor’s care, we will
need a medical clearance form signed by him/her.
3. A pre-addressed envelope for you to return the authorization form
and questionnaire.
After your analysis is complete, you will receive the following:
1. A personalized diet based on your physiological needs with various
instructions and guidelines to follow.
2. A letter with personal counseling from Dr. Muata Ashby, a certified
health consultant or from the certified staff of the Semainstitute. This
tape is personal and confidential, just as though you were being
counseled in person.
3. A pre-addressed envelope for you to return the cassette tape should
you have any questions.
Date_____
Name ___
Address
____
City __ State ___ Zip____
Phone __ email
Are you under a doctor’s care? Yes No
-------------------------------------------------------------
--
Consultation fee enclosed ($75.00)
Payment enclosed: Check _____Money Order
Credit card: Visa, MasterCard, Optima, AMEX,
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