NUTRITION THERAPY INFORMATION AND AGREEMENT
Informed consent is the process by which a fully informed person can participate in choices about his or her health. This consent form is intended to provide you with information about training, the nature of decisions regarding your health, reasonable alternatives to the proposed process, the relevant risks, benefits, and uncertainties related to the alternatives, an assessment of your understanding, and your acceptance of the process. This is an invitation for you to participate in your decisions regarding your health.
Nature of Therapy
My services are not meant to be a substitute for, or replace those of, a licensed physician. I advise you to be under the care of a licensed physician. I do not handle medical emergencies of any kind and refer clients with such emergencies to 911 or the emergency room of their local hospital.
Nutrition Therapy is a conversation about your health, it is not treatment, and it is not a diagnoses.
Suggestion will occur after I have had an opportunity to observe lab work and speak with you. I will discuss the proposed suggestions with you only after I receive your assurance that you understand the situation, understand the risks associated with the decision at hand and you communicate a decision to proceed based on your understanding. I will also advise you of any significant risk, which would affect the judgment of a reasonable trainee. You always have the right to refuse my suggestions entirely.
You agree to advise me regarding your medications, drugs, and aspects of your underlying disease and state of mind that may affect your capacity to make an informed decision. You also agree to advise me if you have ever experienced a fit or fainting, if you have a pacemaker, a bleeding disorder, are taking anti-coagulants, or if you have damaged heart valves or have any other particular risk of infection.
If you are determined to be incapacitated or incompetent to make decisions regarding your health, you agree to provide me with information regarding a surrogate decision maker who can legally speak for you.
Benefits of Therapy
The potential benefits include relief of presenting symptoms and improved function that may lead to prevention, improvement or elimination of the presenting problem.
Risks of Therapy
Potential risks of treatment include allergic reactions, sensitivities, adverse effects to foods, supplements, and adjustments to making lifestyle modifications.
Although this consent form describes major risks of treatment, other side effects and risks may occur.
You agree to take full responsibility for taking any suggestion that I recommend and you agree that I am not liable for any adverse effects or complications from such natural remedies. You agree to cease taking all remedies upon the onset of any adverse effects.
You do not expect that I will be able to anticipate and explain all possible risks and complications of treatment and you wish to rely on me to exercise judgment during the course of treatment which I think at the time, based upon facts then known, is in your best interest. You understand that the results are not guaranteed.
By booking a therapy session you show that you have read or had read to you, this consent to treatment, have been told about the risks and benefits of nutritional and lifestyle therapy, and have had an opportunity to ask questions. You intend this consent form to cover the entire course of your nutrition therapy for your present condition and for any future conditions for which you seek nutrition therapy.
NOTE THAT NUTRITION THERAPY IS USED AT YOUR OWN RISK. I AM NOT LIABLE FOR ANY AND ALL MEDICAL COMPLICATIONS THAT CAN/MAY OCCUR. ALL SALES ARE FINAL, CANCELLATIONS (LESS THAN 48 HOURS)/NO SHOWS/LATENESS WILL OCCUR A FULL 100% CHARGE OF SESSION FEE. LAST MINUTE EMERGENCIES CAN ONLY BE EXCUSED IN CASE OF MEDICAL EMERGENCY OR DEATH.