CONSENT TO TREATMENT, USE OF PROTECTED HEALTH INFORMATION & TERMS OF SERVICES
I,_______________ understand that online or phone nutrition counseling and therapy services provided by Force of Nature Nutrition LLC., Galina Goldstein, RD, CNSC (Registered Dietitian, Certified Nutrition Support Clinician), are not intended as a substitute for a medical diagnosis, medical treatment and/or consultation with a physician. I have read Force of Nature Nutrition LLC. MEDICAL DISCLAIMER, WEBSITE DISCLAIMER, TERMS & CONDITIONS, and PRIVACY POLICY and agree with all of the above. I hereby consent to participate in nutrition services and understand that all information I provide is private, confidential, and protected by law. I understand that it is my responsibility to report to Galina Goldstein, RD and/or my treating physician any changes I make to my diet, exercise program, and/or other nutritional therapies, and any side effects I may experience from diet modifications, exercise or other nutritional therapies, so an adjustment to my treatment can be made immediately. I will not hold my physician or Galina Goldstein, RD responsible for any complications that result from my failure to comply with the above. When necessary for my treatment and/or coordination of my healthcare services, I authorize Force of Nature Nutrition LLC., Galina Goldstein, RD to use, obtain or share my Protected Health Information with other health care providers only with my permission or request unless otherwise permitted or required by law. I agree to hold Galina Goldstein, RD, harmless for claims or damages in connection with our work together. This is a contract between myself and Force of Nature Nutrition LLC., and I understand that it is also a release of potential liability.
Your name below indicates your agreement.
Name ________________________Date _________________________
Name of Legal Guardian______________________Date_________________________