Patient Form

Complete the form below to begin your Journey

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
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.

General Enquiries

To book a consultation, feel free to contact us.

  • 011 884 4973
  • 17th Floor, Sandton City Office Towers, Sandton, Johannesburg
Patient Form 1

Eden Life Wellness Clinic is a professional team aimed at getting the best results for your health!