Nutritional Counseling and Treatment Informed Consent

Client Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Nutritional Services

I, _________________________, hereby consent to receive nutrition counseling and treatment services from [Practitioner Name], a licensed/registered dietitian/nutritionist.

Understanding of Services

• I understand that nutrition counseling involves:
  • Assessment of nutritional needs and eating habits
  • Development of personalized nutrition plans
  • Goal setting and monitoring of progress
  • Education about nutrition and dietary choices

Acknowledgments

I acknowledge and understand that:

1. Results from nutritional counseling may vary and no specific outcomes are guaranteed
2. Successful outcomes require my active participation and adherence to recommended dietary changes
3. My nutritional care may involve coordination with other healthcare providers
4. I am responsible for informing the practitioner about:
   • All current medications and supplements
   • Medical conditions and allergies
   • Changes in health status or medications

Financial Agreement

• I understand the fee structure for services
• I am responsible for payment of services rendered
• I will provide 24-hour notice for cancellations

Privacy Notice

I acknowledge that I have received and reviewed the Notice of Privacy Practices, which explains how my medical information will be used and disclosed.

Signatures

Client Signature: _________________________ Date: _____________

Practitioner Signature: ____________________ Date: _____________

Emergency Contact

Name: _________________________ Phone: ___________________ Relationship: _____________________

This document is valid for one year from the date of signing unless revoked in writing.