Consent Form

I, hereby grant permission for the dietitian to collect personal information including my name, date of birth, phone number, email address, medical history, medications, supplements, food allergies/intolerances, food intake records, food or nutrition-related concerns, lab values accessed through interview assessment and Netcare, and any other information pertinent to the nutrition service provided. This information will be used for nutrition assessment, sustainable planning, and follow up counseling and coaching.

I also grant permission for the dietitian to correspond with my physician(s) or pertinent health care provider(s) to obtain or share information relevant to my nutrition treatment and counseling, as needed, at any time during the course of my care and consultation with Food First Nutrition Consulting.

I am aware that my personal health information will be retained for ten years following the last date of service, or ten years following my eighteenth birthday, whichever is longer and then destroyed in compliance with provincial privacy legislation (HIPA). I also understand that I have the right to view the health information in my file and to review the privacy policies of Food First Nutrition Consulting.

Payment

The fee schedule for Dietitians services and programs has been explained to me. I understand that all consultation services are payable by cheque, electronic transfer, cash or credit card to Food First Nutrition Consulting and are due at time of the initial consultation. GST and PST are not added to Dietitian services. Receipts are issued for both packages and individual nutrition consultation sessions. Packages expire 90 days from the date of purchase. Packages are non-refundable.

Appointment Cancellation

I understand that 24-hours notice is requested to cancel or reschedule appointments. Failing to attend a scheduled appointment without communication with the Dietitian will be deemed as services rendered.

I agree to all of the above.

Full name:

Check this box do verify your electronic signature.

Signature of Dietitian:

Emily Mardell, Registered Dietitian

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