MEMBERSHIP AGREEMENT FORM

Herban Healing Association

This agreement is between _______________, the member, and Adam Souza, for the express purpose of exchanging information in regards to gaining health the natural way. The information given by Adam Souza is based upon Nature’s laws.

I, the client, give Adam Souza my permission (all rights) to discuss openly and freely

my health issues and solutions to these issues, between ourselves. ALL information is strictly

Confidential. Adam Souza is bound by Counseling Confidentiality.

I attest that I am here, on this and any subsequent visit, solely on my own behalf and not as

an agent or representative for any government, state, or agency on a mission of entrapment

or investigation.

I fully understand that Adam Souza is not a medical doctor and I am not here for medical

diagnostic or treatment procedures.

The information given by Adam Souza is at all times limited strictly for my educational

purposes and only on the subject of health matters. This information is intended for the best

possible state of health and does not involve the diagnosing, prognosticating, treatment, or

prescribing of remedies for the treatment of diseases.

All diet, nutritional, herbal, homeopathic, fasting, and other health information and

suggestions received by me from Adam Souza is for my personal information only. If I

choose to follow any of the information received, I do so on my own behalf, and on my own

decisions based upon my personal beliefs.

If I use any information to treat a disease process without my medical doctor’s approval, I

am prescribing for myself and exercising my Constitutional Rights.

I assume total and all responsibility and liability for my actions.

This agreement is to establish mutual trust, relationship, and understanding. Therefore, by

printing & signing my name, I acknowledge that I have read the above and agree to the

terms stated. This affidavit is agreed by me without coercion or remuneration.

_______________________ ____________________

Client Signature Practitioner signature 

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Date