New Client Form

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Name
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Phone
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Address
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Please tell me any preexisting conditions of which you know, dietary habits, or anything else you feel might be relevant. The more info the better. If no notable conditions or information, then just put "none".
Be as descriptive as possible with your goals. Having a clear understanding of what you would like to achieve helps us both.
How did you hear about Heal Your Disease?
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If someone referred you, please enter their name here.
I like to thank those that send me new clients.
Disclaimer *
By checking the box below, you understand and agree that... 1. Derek Weaver is not a doctor or medical professional. 2. Any information you receive from Derek Weaver or HealYourDisease.com must not be construed as a diagnosis, treatment, cure, prevention, or medical advice of any kind. 3. Derek Weaver and HealYourDisease.com disclaim any responsibility or liability for any loss or injury incurred as a consequence of the use of this website or information received by Derek Weaver. 4. If you have a health concern or condition, you should consult a physician. 5. You should always consult a medical doctor before modifying your diet, using any new product, drug, supplement, or doing any new exercises. 6. All information provided by Derek Weaver or HealYourDisease.com only intends to suggest the potential of herbs, organic foods, and the body’s own healing abilities. 7. You are responsible for your own choices and your own health. 8. You are responsible for paying Derek and HealYourDisease.com a consultation fee for Derek's time at the following rate: Phone calls are $1 per minute with a $5 minimum per call. In person visits are $60 per hour with a 1 hour minimum per visit. 9. In person visits also require a travel fee for time and any travel costs incurred outside of the Broadripple Village, Indianapolis, IN zip code 46220 area. My travel fee is $15 per hour travel time and the cost of travel expenses such as but not limited to fuel, lodging, airfare, rental car and/or shuttle service such as Uber. 10. You are responsible for paying your consultation fee and any additional fees within 30 days of receiving your invoice. 11. You will be responsible for a $10 late fee for each invoice not paid within 30 days of being received. 12. You will be responsible for a $30 cancellation fee plus any additional incurred travel costs for canceling within 24 hours of our scheduled meeting time or for not showing up to our scheduled meeting. 13. You will not receive any consultation help from Derek or HealYourDisease.com until all outstanding invoices and late fees are paid in full. 14. You may be blocked and/or no longer receive consultation help from Derek or HealYourDisease.com if you are deemed rude, vulgar, disrespectful, or in any way waste Derek's time.