Nutrition Treatment Agreement and Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Phone: ________________________ Email: ________________________

Agreement Terms

1. Services

I understand that [Nutritionist Name], a licensed nutritionist/registered dietitian, will provide nutrition counseling services including:

• Nutritional assessment
• Personalized meal planning
• Dietary recommendations
• Ongoing nutrition monitoring
• Educational resources

2. Financial Responsibility

• Initial consultation fee: $_______
• Follow-up session fee: $_______
• Cancellation policy: 24-hour notice required
• Late cancellation/no-show fee: $_______

3. Communication Policy

• Response time: Within 24-48 business hours
• Emergency contacts are not provided; seek immediate medical care if needed
• Email communication is for non-urgent matters only

4. Privacy & Confidentiality

I acknowledge that my personal and health information will be protected according to HIPAA regulations. Information may be shared with other healthcare providers with my written consent.

5. Informed Consent

I understand that:

• Nutrition therapy is not a substitute for medical treatment
• Results vary and cannot be guaranteed
• I am responsible for informing the nutritionist of any health changes
• I can terminate services at any time

6. Client Responsibilities

I agree to:

• Provide accurate health and dietary information
• Follow agreed-upon treatment plans to the best of my ability
• Attend scheduled appointments
• Maintain open communication about progress and concerns

Signatures

Client Signature: _________________ Date: _______

Nutritionist Signature: ____________ Date: _______

License Number: __________________