Telehealth Nutrition Consultation Consent Form

I, [Patient Name], hereby consent to participate in telehealth nutrition consultations with [Provider Name], RD/RDN.

Nature of Telehealth Services

• Virtual consultations conducted via [Platform Name]
• Nutrition assessment and counseling
• Diet planning and monitoring
• Follow-up care and modifications

Understanding and Agreements

1. I understand that:

   • Telehealth involves the use of electronic communications
   • Technical difficulties may necessitate rescheduling
   • The same standard of care applies as in-person visits
   • Privacy limitations exist with electronic communications

2. I acknowledge that:

   • My nutrition care information will be shared via secure electronic means
   • I am responsible for ensuring a private, quiet environment during sessions
   • I must provide accurate and complete health information

Privacy and Security

• All sessions are conducted through HIPAA-compliant platforms
• Sessions will not be recorded without separate explicit consent
• I will not record sessions without provider permission

Financial Agreement

I understand that:

• Payment is due at time of service
• Cancellations require 24-hour notice
• Insurance coverage for telehealth varies by provider

Emergency Procedures

In case of emergency during a telehealth session:

• Emergency contact: [Name and Phone]
• Local emergency services: [Phone/Address]

Signatures

Patient Signature: _______________ Date: _______________

Provider Signature: ______________ Date: _______________

License #: _______________