Nutritional Care Agreement and Treatment Contract

Patient Information

Name: _________________________ Date of Birth: _____________ Phone: _________________________ Email: ____________________

Agreement Terms

1. Services

I, ___________________, agree to receive nutrition counseling services from ___________________ ("Provider"). These services may include:

• Nutritional assessment and evaluation
• Personalized meal planning
• Dietary recommendations
• Progress monitoring
• Follow-up consultations

2. Patient Responsibilities

I agree to:

• Provide accurate medical and dietary history
• Follow agreed-upon nutritional recommendations
• Attend scheduled appointments
• Notify the provider 24 hours in advance of cancellations
• Pay for services as outlined in the payment terms

3. Provider Responsibilities

The Provider agrees to:

• Maintain patient confidentiality per HIPAA regulations
• Provide evidence-based nutritional guidance
• Document all consultations and recommendations
• Communicate with other healthcare providers as authorized
• Provide timely responses to patient inquiries

4. Payment Terms

• Initial consultation fee: $_______
• Follow-up consultation fee: $_______
• Payment is due at time of service
• Accepted payment methods: ___________________

5. Cancellation Policy

• 24-hour notice required for cancellations
• Late cancellations subject to $___ fee
• No-shows will be charged full session fee

Signatures

Patient Signature: _________________ Date: _________

Provider Signature: ________________ Date: _________

License/Certification #: ___________