PERSONAL USE EXEMPTION FORM

AND AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

________________________________________                               ___________________________________

NAME                                                                                                                DATE

________________________________________                                ___________________________________

ADDRESS                                                                                                          BIRTHDATE

________________________________________                                ___________________________________

CITE, STATE, ZIP                                                                                             TELEPHONE NUMBER

To Whom It May Concern:

I have learned about Enercel^TM homeopathics without any solicitation from you. You have informed me that no claim is made that they will mitigate, diagnose, treat, prevent or cure any particular disease or condition.

I am presently suffering from _______________________________, which my doctor has told me is compromising my health and/or is threatening my life.

I would like to purchase a three-month supply of Enercel^TM for my personal use only, and I will not resell it.

I understand the importance of keeping a comprehensive database. Therefore, I am providing authorization for the obtaining of all my medical records, copies of blood-work or other data supporting the diagnosis from any office, clinic, hospital, laboratory or medical facility by any personnel of World Health Advanced Technologies, 2477 Stickney Point Road, Suite 200A, Sarasota FL 34231.  Telephone number: 941-927-3444; Fax number: 941-927-3477.

I consent to your entering my medical data into your database for statistical and research purposes, as long as my name and address are kept confidential.

Very truly yours,

_______________________________________________

Signature

The listed physician who will monitor my health is: