Nutrition Consultation - Client Information & Consent
Thank you for filling out our Client Information and Consent form and providing your contact information. This form helps us get in touch, provides a brief overview of health information for nutrient recommendation purposes, and informs our clients of their rights to confidentiality as we work together.
First Name
Last Name
Age
Date of Birth
Address
Phone Number
May we leave confidential messages for you at the above phone number?
Yes
No
Email
May we contact you by e-mail? We value your privacy and will never share your e-mail address.
Yes
No
Primary Care Physician (Optional)
Physician's City, State and Country (Optional)
Briefly describe the reason for your visit and what you hope to accomplish:
What are the top three symptoms you hope to address?
What is your current height?
What is your current weight? (This helps inform DRI recommendations.)
What is your desired weight? (Optional)
How did you hear about us? (Optional)
Any additional comments? (Optional)
CONFIDENTIALITY AGREEMENT
Nutrition consulting/education is a confidential process designed to help you address your health concerns, come to a greater understanding of yourself and the relationship that diet and lifestyle practices have on one's health, and learn effective dietary, lifestyle, supplemental, and stress management strategies. It involves a relationship between you and a nutritional practitioner who has the desire and willingness to help you accomplish your individual goals. All information gathered from the client, including name, contact information, and medical history is secured and confidential. Any views expressed by the client to the practitioner will be held with the utmost confidentiality. Information will be only released with the consent of the client unless said information may be potentially injurious to a third party.
CONSENT
I, the client, have read and understand the information about the holistic health services offered by the practitioner at Living Nutrition and Wellness, LLC. I have discussed with the practitioner the nature of the services to be provided. I understand that the practitioner is not a licensed physician and as such, cannot diagnose, treat, or prescribe medications. I understand that the information provided on the relationship between nutrition, lifestyle, health, and bio-energetic devices including ZYTO and BioMeridian is NOT meant to replace competent medical care or treatment for any health problem or condition and that it is my responsibility to maintain a relationship for myself / child with a medical doctor or licensed health care practitioner. The nature of nutrition assessment and evaluation and bio-energetic devices is to support the learning process of the client and practitioner and to support client wellness through food, herbs, nutritional supplements, education, exercise programs, and lifestyle changes. I certify that I am here solely on my behalf. I am not representing any other person, company, association, and/or on behalf of any governmental agency. I, the client, give consent to the nutritional assessment, bio-energetic assessment, and functional evaluations as requested by the client, offered by the practitioner at Living Nutrition and Wellness, LLC.
I agree to the terms & conditions
Your Signature
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