Supplement Consent Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Doctor's Name: Dr. Ping Jaa Dr. Paul Payton Dr. Jane Chapman Dr. David Jaa I, (patient's name): * of (patient's address) * Understand that: Some, or all of the nutrients could be at much higher dosages than that which is specified by the recommended daily intakes by NHMRC (National Health and Medical Research Council). It is important that I take these prescribed supplements as directed by Dr David Jaa. I will return for review of my health at date which is specified by Dr David Jaa. If I fail to attend these reviews then I will no longer take any of the supplements prescribed to me by Dr David Jaa after the specified review date. I understand that these supplements are only prescribed for me and are not to be used for anyone else. I understand that prolonged taking of certain supplements at high dosage without medical supervision could lead to adverse health outcomes such as nerve and thyroid disorders. I will direct any question of concerns to my Doctor during my consultations. Some of the products are not TGA listed and may need a SASB form willed in on my behalf. The Pfeiffer / Iodine / Amino Acid Nutritional protocol includes high doses of B6, iodine, lithium, selenium and molybdenum. These doses need to monitored. Please stop the therapy and inform the doctor if you experience any of the following: Tingling in hands, feet and tongue Metallic tastes in the mouth Undue fatigue or agitation Worsening of your condition Patient Consent: * Date: * Confirm that you are not a bot * Employees of Dr Jaa's Medical Health and RPPR are independent health contractors. Therapy not endorsed by Dr Jaa or Dr Jaa's Medical Health as way of written referral is considered the legal responsibility of the independent contractor.