Functional Blood Work Review: Client Information & Consent-Living Nutrition & W

Functional Blood Work Review: Client Information & Consent

Hi! 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.

For functional blood work analysis and review, please email your blood work at least 3 business days before your appointment to allow time to review and make recommendations. E-mail it to: laura@livingnutritionwellness.com. Thanks!

First Name

Last Name

We look forward to meeting with you! Briefly describe the reason for your visit and what you hope to accomplish.

Do have any any current health concerns and/or symptoms? Please share your top 3 below, in order of importance to you.

Age

Date of Birth

May we contact you by e-mail? We value your privacy and will never share your e-mail address.

Yes

Phone Number

May we leave confidential messages for you at the above phone number?

Yes

Address

Do you have any diagnosed medical conditions? Please list them here, or write "none".

Current Medications:

Current Supplements:

Please include any relevant family medical history you would like us to consider below. Remember that a healthy diet, lifestyle, and environment can greatly improve your health and how your genes express themselves.

What is your current height?

What is your current weight? (This helps inform DRI recommendations.)

What is your desired weight? (Optional)

Primary Care Physician

Physician's City, State and Country

Is there anything else you would like us to know?

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, tests, 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, bio-energetic devices including ZYTO and BioMeridian, and functional bloodwork review (FBWR) 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 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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