“Request for Advice” form

  About the author >> Schedule your personal consultation with Aajonus Please print a copy of this form, fill in the blanks (please print), sign and
fax to (310)589-0470:

Name___________________________________ Age: _____ Height: _____ Weight:___

Address:_________________________________________ City: ____________________

State: _________________ Zip: ____________ Phone: ________________

Email address: ____________________ Referred by: _____________________________

Individual freedom, and the recognition and development of the spiritual nature of mankind are the essence of democracy. They are the essence of life. The Ninth Amendment to the Constitution of the United States of America makes a declaration of the sovereignty and dignity of the individual clear and coherent.

Notice and Declaration of 9th Amendment Rights
The enumeration in the Constitution of certain rights shall not be construed to deny or disparage others retained by the people.

I, the undersigned, hereby declare the following natural and God-given rights as retained by the people, under the 9th Amendment to the Constitution of the United States of America and which rights I reserve to myself as follows:

I reserve the right to seek or ask advice, counsel, information, recommendations, evaluations, analyses, assessments, test and/or care, regimens, modalities or treatments from ANY person of my choice, regardless of state sanctions, for any reason or purpose I so desire.

I reserve the right to select or reject ANY individual as my personal advisor, minister, druggist, nurse, nutritionist, herbalist, naturopath, teacher, practitioner, priest, pastor, relative, friend, or anyone from the general citizenry who has, or has not, any known formal training or claimed knowledge, education, insights, qualifications or credentials.

I reserve the right of freedom of choice in matters pertaining to my spiritual, mental, emotional, and physical well-being. I reserve this right in the most liberal way. My freedom, with regard to my personal life, circumstances, well-being and the decisions I make, include the right to choose my own religion, to choose with whomever I wish to associate, obtain purchase and use any treatment technique, regimen, process, modality, herb, drug, food, diet, medicine or health product for any health condition I have whether determined by myself, a physician, therapist, layman, or by anyone of my choice. I do not relinquish these rights to others.

The enumeration, in this declaration, of these rights shall not be construed to deny or disparage others retained by me, or my right to amend this declaration at any time.

I am herewith presenting this declaration to uphold my rights. In this regard, the holder of this document is authorized to deliver copies of this declaration to anyone if such a need were to arise.

Constructive Notice: Notice is hereby given to any person or persons who receive a copy of this declaration, and who acting under color of any law, intentionally interferes with the free exercise
of my rights under the 9th Amendment, as enumerated in this document, and any I retain but not stated herein, that they may be in violation of Title 42 U.S.C. 1983 et seq. and Title 18, Section 241.

Date: _________________ Signature: ___________________________________

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