Informed Consent Form
I acknowledge that the purpose of this program is to help me improve my health, wellness and lifestyle.
I am employing the services of [Laura Davis, NTP] so I can obtain information and guidance about health factors within my own control (such as diet, hydration, lifestyle, wellness and various other related behaviors) in order to help support my overall health and wellness.
I understand that she is a nutritional educator and does not dispense medical advice nor prescribe treatment. Rather, she provides education to enhance my knowledge of an overall healthy lifestyle. I understand that while very useful, this guidance is not a substitute for the diagnosis, treatment, or care of a disease, illness, or injury by a medical provider.
Nutritional evaluations and lifestyle assessments are not intended for the diagnosis of disease. Rather, these are intended as a guide for the development of a nutritional program and used to monitor my progress in achieving my health and wellness goals.
I understand that [Laura Davis, NTP] will keep all documents related to me (including but not limited to, assessments, food diaries, forms, worksheets, audio, transcripts, video, or images) and any notes that relate to me as a record of our work together. Records will be stored in a secure location.
Medical records, personal information and health history divulged to [Laura Davis, NTP], in or out of session will be kept strictly confidential unless I consent to sharing this information by way of a signed release.
I understand that every person is unique, and it is not possible to determine in advance how my system will react to certain foods, drinks, supplements, or dietary products that may be suggested to me. I agree that it may be necessary to adjust my plan accordingly until my body can begin to properly accept nutritional changes. I accept that it is my responsibility and decision to use or disregard nutritional, exercise and lifestyle guidelines. It is also my responsibility to hydrate well, get plenty of rest and learn about nutrition.
I agree not to hold [Laura Davis, NTP] liable for any claims or damages in connection with our work together under the terms of this consent form. I understand that this consent form is a release of her liability. I accept that the advice under this program is not a guarantee for health improvements or for reaching my health goals.
I agree that I will inform [Laura Davis, NTP] if there is any reason why I should not continue; for example, an illness or injury that requires medical assistance or advice. If at any time, I experience pain or excessive discomfort, I will stop the program undertakings immediately and inform [Laura Davis, NTP] of my symptoms. I am, at all times, responsible for seeking medical help where appropriate.
I understand the intellectual property rights and privacy of all the materials and information provided to me during this program. I agree to use the session handouts, worksheets, and questionnaires for my own personal (non-commercial) purposes only and that I will not share, copy, or distribute them to third parties.