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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__________