Patient Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastContact Number *Email *Chronic Medication and/or Allergies (If Applicable) *Delivery/CollectionDeliver to My DoorI Will Collect (Sandton, JHB)Delivery AddressAge (Optional)Approximate Height (Optional)Current Weight (Optional)Dream Goal Weight (Optional)By Checking the Below Box you Accept our Terms & Conditions *I Accept the Terms & Conditions of SaleCONDITIONS OF SALE Eden Life Wellness Clinic shall be referred to hereafter as the COMPANY. 1. The COMPANY’S products are sold to the patient on a cash on delivery basis only unless prior arrangements are made for payment on terms in which event the conditions of sale shall only be effective if the same are reduced to writing, any amounts paid after 30 days will attract an interest of 21% per annum. 2. Where a written medical doctor’s prescription is required the COMPANY will not release any of its products to the patient without the original prescription first being submitted. 3. The patient irrevocably undertakes not to disclose, publish, make known or in any way communicate to any third party any of the COMPANY’S weight reduction methods, diet recommendations, exercise schedule or product identity or any other aspect of the COMPANY’S products or services of any nature whatsoever. 4. The patient hereby indemnifies the COMPANY, its employees, representatives, agents and all persons who act or purport to act on behalf of the COMPANY against all liability proceedings of whatsoever arising including damages whether direct or indirect, general or special or punitive resulting directly or indirectly from the COMPANY’S weight reduction programme or any medicine, food supplement other substances given, dispensed, prescribed or recommended to the patient. 5. The COMPANY makes no representations or warranties of any nature whatsoever relating to the use of the weight reduction programme, treatment or any other aspect of the treatment, medicine, diet or substance given or recommended to the client neither does it give any warranties whether express or implied as to the effectiveness of the treatment or weight reduction programme and does not warrant in any way that the patient will loose weight as a result of any or all aspects of the services or products rendered, supplied or recommended by the COMPANY. 6. It is the specific intent of these conditions release and discharge any or all claims and causes of action of any kind or nature whatsoever, whether known or unknown whether specifically mentioned or not, which may exist or might be claimed by the patient from the COMPANY, its employees, representatives, agents, distributors or any other persons who act on behalf or make any representations for and on behalf of the COMPANY. 7. The patient chooses as its domicilium citandi et executandi the address chosen by the patient on the reverse hereof under the heading residential address for the service of all documents and legal process. 8. The patient warrants that he/she has made a full disclosure to the COMPANY relating to all aspects of his/her health (psychological and physiological), any allergies, other medicines (prescribed or otherwise) currently being consumed and any other circumstances or conditions which may be relevant which may affect the COMPANY’S recommendations as to diet, medicines or treatment.MessageSubmit