Telomerase Acknowledgement

DR. SEARS’ CENTER FOR HEALTH & WELLNESS
11903 Southern Blvd., Suite 208
Royal Palm Beach, FL 33411
561-784-7852

PATIENT ACKNOWLEDGEMENT FORM

This Customer Acknowledgement Form is between

Patient Name (required)

Your Email (required)

and Al Sears, MD Center for Health & Wellness and Telomerase Activation Sciences, Inc. (the “Suppliers”). This is a legally binding document.


INSTRUCTIONS: PLEASE READ THIS FORM THOROUGHLY AND, IF YOU CONSENT TO ITS CONTENTS, WRITE YOUR NAME AND SIGN AND DATE THE FORM ON THE DESIGNATED LINE AT THE END OF THIS FORM. YOUR SIGNATURE CONFIRMS YOUR CONSENT AND AGREEMENT TO THESE TERMS AND INDICATES TO THE SUPPLIERS THAT YOU UNDERSTAND THIS FORM.


I. Background.

I would like to use Telomerase Activation Sciences’ new non-prescription Telomerase Activation nutritional supplement product known as TA-65® (the “Product”) for a limited time in accordance with the instructions provided by the Suppliers Before taking the Product, I may or may not have undergone certain tests, evaluations and consultations with the Suppliers; however the final decision to receive and take the Product is mine and mine alone. Prior to receiving the Product I understand that I first must read, understand and agree to the contents of this Form.

II. Customer Representations.

A. I am over the age of twenty-five (25) years.

B. My use of the Product is entirely voluntary.

C. I acknowledge that I am a customer of the Suppliers with respect to use of the Product, my use of the product being in a commercial setting. However, I hereby authorize the Suppliers at their sole discretion to use the results of any tests or evaluations, including my medical history, for research and learning purposes, including the publishing thereof, so long as my individual records and identity are concealed. At my request, the Suppliers will share with me the results of any and all tests which might be considered experimental in nature.

D. I understand that use of the Product may involve risks to me which are currently unforeseeable. I understand that it is recommended that I not use the product if I have cancer or have had cancer within the last 5 years, if I am pregnant, nursing, or might become pregnant.

E. I agree to provide complete and accurate information to the Suppliers in connection with my use of the Product, including any services or evaluations being performed in connection with the Product.

F. I will not permit anyone else to use the Products provided to me.

G. If I choose to use any Product, I will use it solely in accordance with the instructions provided by the Suppliers or as shown on the Product label.

H. If I choose to use any Product, I will do so under the supervision of Dr. Al Sears Center for Health & Wellness.

I. I UNDERSTAND THAT THE SUPPLIERS DO NOT REPRESENT OR WARRANT THAT THE PRODUCT WILL PROVIDE ANY BENEFIT TO ME.

III. RISKS OF THE PRODUCT.

A. I understand that while the Product has no known side effects, individual reactions may vary. I will alert Dr. Al Sears Center for Health & Wellness if I experience any significant discomfort or adverse reaction related to taking the Product.

B. I understand that potential adverse events and risks of taking the Product exist. Although the Product is not known to cause or contribute to progression of cancer in humans, and to T.A. Sciences’ knowledge no experiments in human cells or in animals have shown that the Product causes cancerous changes, some studies in mice using telomerase gene transduction where telomerase is dramatically increased and the gene is permanently turned on, have shown an increased incidence of cancer compared to mice that are not transduced with the telomerase gene. (Note that while the Product, TA-65, activates telomerase, it does not dramatically increase the enzyme like splicing in a gene does and taking TA-65 has a transient effect; it does not permanently turn on telomerase.)

B. I also understand that the use of this product carries the risk of potentially unknown adverse events.

C. I understand that I may not benefit from the use of the Product.

D. I understand that the scientific and medical community may learn more about the Product and the effects of using the Product over time. I also understand that such knowledge may make it possible to have more precise, or more predictive, models for how individuals might respond to the Product.

IV. Withdrawal from Use/Refusal to Use Product.

A. I acknowledge that I am not required to use the Product; however, if I do use the Product, then I agree to do so only in accordance with the labeling or instructions provided by Dr. Al Sears Center for Health & Wellness.

B. I understand that I may choose not to use the Product at any time.

C. Refusal to use the Product will involve no penalty or loss of benefits from the Suppliers to which I am otherwise entitled.

V. DISCLAIMER OF WARRANTIES.

TO THE EXTENT PERMITTED BY LAW, THE PRODUCT AND ANY ASSOCIATED CONSULTATION AND EVALUATION SERVICES AND RESULTS, INCLUDING ALL REPORTS AND INFORMATION PROVIDED BY THE SUPPLIERS ARE “AS IS” AND HAVE BEEN PROVIDED TO YOU WITHOUT EXPRESS OR IMPLIED WARRANTIES OF ANY KIND. THE SUPPLIERS DISCLAIM ALL SUCH WARRANTIES INCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE.

VI. LIMITATION OF LIABILITY FOR DR. AL SEARS CENTER FOR HEALTH & WELLNESS, ITS REPRESENTATIVES, and TELOMERASE ACTIVATION SCIENCES, Inc.
TO THE EXTENT PERMITTED BY LAW, (NAME OF LICENSEE) AND TELOMERASE ACTIVATION SCIENCES, Inc., THEIR CONSULTANTS, SUPPLIERS, AFFILIATES, SUCCESSORS AND ASSIGNS SHALL IN NO EVENT BE RESPONSIBLE OR LIABLE FOR INDIRECT, INCIDENTAL, CONSEQUENTIAL, OR SPECIAL DAMAGES, HOWEVER ARISING, WITH RESPECT TO THE USE OR RECEIPT OF ANY PRODUCT, OR ANY ASSOCIATED CONSULTATION OR EVALUATION SERVICES BY THE SUPPLIERS, AND I WILL NOT HOLD ANY OF THEM LIABLE FOR SUCH DAMAGES.

VII. Contact Information.

In the event that you have any questions or comments please contact:

Dr. Al Sears’ Center for Health & Wellness
11903 Southern Blvd., Suite 208
Royal Palm Beach, FL 33411
561-784-7852

Or:
Telomerase Activation Sciences, Inc.
www.TAsciences.com

VIII. Other Legal Terms

A. Governing Law. This Form shall be governed by, and construed and interpreted in accordance with,
the laws of the State of Florida (without giving effect to the laws, rules or principles thereof regarding conflicts of laws).

B. Severability. If any provision of this Form is held by a court of competent jurisdiction to be invalid, unenforceable, or void, the remainder of this Form shall remain in full force and effect. No part of this Form may be amended other than in a writing signed in triplicate by me, Dr. Al Sears Center for Health & Wellness, and by an officer of Telomerase Activation Sciences, Inc.

C. In the event that the Product causes a reaction or other side effect, and I wish to discontinue usage, upon the return of the unused portion a prorated refund will be made within 30 days of return of product.


By writing my signature in the space below, I am certifying and confirming that:

1) I am providing my legal signature to this document;
2) I desire and consent to the use of the Product and any associated consultation or evaluation services in connection thereof provided by the Suppliers;
3) I have been given a chance to ask questions of the Suppliers’ personnel regarding the Product and all of my questions were answered;
4) I agree to use the Product in accordance with the terms and conditions of this Form;

5) All information I have provided to the Suppliers is accurate and complete;
6) I HAVE READ AND UNDERSTAND AND ACKNOWLEDGE THE ABOVE INFORMATION, INCLUDING THE DISCLAIMER OF WARRANTIES AND LIMITATION OF LIABILITY PROVISIONS, AND BY MY SIGNATURE BELOW I ASSUME THE RISK OF USING THE PRODUCT, UNDERGOING THE EVALUATION AND THE OTHER RISKS SET FORTH ABOVE; and
7) I am consenting to this process of my own free will.
8) By sending this electronic file, it is a confirmation of my agreement to all these terms.

Name of Individual or Personal Representative (required)

Date: (required)