Download Informed Consent to Nutrition Counseling

Evolution Fitness and Sports Training LLC
613-615 Morris Avenue
Springfield NJ, 07081
973-376-0623
Informed Consent to Nutrition Counseling
Date of Consent:_________________________________________
Client Name:____________________________________________
Birth date of Client:______________________________________
GOAL: The nutritionist’s goal is to encourage patients to become knowledgeable about and
responsible for their own health and to help them to reach a personal optimum level. Nutritional
counseling is designed to improve your health, but is not designed to treat any specific disease
or medical condition. Reaching the goal of optimum health, absent other non-nutritional
complicating factors, requires a sincere commitment from you, possible lifestyle changes, and a
positive attitude. The nutritionist will evaluate your nutritional needs and make recommendations
of dietary change. The nutritionist may use laboratory analysis to help investigate your nutritional
needs. The services provided by the nutritionist shall include, but not be limited to, nutritional
assessment of eating behaviors and beliefs, strategies to overcome barriers to change,
suggestions for moderate physical activity (using guidelines established by patient’s healthcare
providers), use of counseling therapies, routine follow-ups and re-evaluations as you learn and
practice new lifestyle choices.
Patient acknowledges and understands that treatments and advice will be made in their best
interest using the information provided by them. The nutritionist will exercise judgment based
upon current scientific research and patient’s unique physical and psychological characteristics.
The nutritionist is not trained to provide medical diagnoses, and no comment or
recommendation should be construed as being a medical diagnosis. Since every human being
is unique, the nutritionist cannot guarantee any specific result from a recommendation.
HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need
to consult with an appropriate healthcare provider. Consulting with the nutritionist is not a
substitute for being treated by your primary care provider or other appropriate healthcare
practitioner. The nutritionist is not trained nor licensed to diagnose or treat pathological
conditions, illnesses, injuries or diseases.
If you are under the care of another healthcare provider, it is important that you contact said
healthcare provider and alert them to the fact that you will be embarking on a program of
nutritional counseling. Nutritional counseling may be a beneficial adjunct to more traditional
care, and it may also alter your need for medication—thus it is important that always keep your
physician informed of changes to your nutritional program. If you are using medications of
any kind, you are required to alert the nutritionist to such use, as well as discuss any potential
interactions between medications and the nutritional changes to your diet. If you have any
physical or emotional reaction to nutritional therapy, discontinue use immediately, and contact
the nutritionist to ascertain if the reaction is adverse or an indication of the natural course of the
body’s adjustment to therapy.
RELEASE OF INFORMATION: Patient hereby authorizes the release of medical information
discussed at this nutritional counseling to his/her personal physician and pertinent healthcare
professionals involved in their ongoing care, including copies of records needed for provision of
care.
Patient understands that the nutritional guidance provided by the nutritionist along with all
printed nutritional material provided to them are solely for their use.
INSURANCE: Medical insurance companies may or may not offer coverage for nutritional
counseling. Investigate the type of coverage that you have by calling the toll free member
services number on the back of your insurance card. It is the responsibility of the patient to pay
for their visits, and that the receipt provided may be self-submitted for potential insurance and/or
healthcare savings account reimbursement.
PAYMENT: I understand that payment is expected at the time of the appointment. Checks should
be made payable to Evolution Fitness and Sports Training LLC. If there is difficulty making
payment at the time of the visit, please negotiate this with the nutritionist at the time of the initial
visit.
By my/our signature(s) below, I/we confirm that I/we have read and fully understand the above
disclaimer, are in complete agreement thereto and do freely and without duress sign and
consent to all terms contained herein.
CLIENT NAME___________________________________________________
CLIENT NAME___________________________________________________
SIGNATURE_______________________________________DATE_________
SIGNATURE_______________________________________DATE__________