INFORMED CONSENT FORM & TERMS FOR WEIGH FOR WELLNESS PROGRAM
I am employing the services of Weight For You, LLC so that I can obtain information and guidance about health factors within my own control (diet, nutrition, and related behaviors) in order to nourish and support my health and wellness.
I understand that the Weigh For Wellness Program does not dispense medical advice nor prescribe treatment. Rather, provides education to enhance my knowledge of health as it relates to foods, dietary supplements, and behaviors associated with eating. While nutritional and holistic support can be an important compliment to my medical care, I understand nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider.
Victoria Goodwin, is not a physician or psychologist, and the scope of her consultation services does not include treatment or diagnosis of specific illnesses or disorders. If you, the client, suspect you may have an ailment or illness that may require medical attention, then you are encouraged to consult with a licensed physician without delay. Only a licensed physician can prescribe drugs. Any mention of drugs in the course of consultation is only for the purpose of providing a complete history of drugs that the client is taking and not for Victoria Goodwin MA RD LDN to judge the appropriateness of the medication. Any change in prescription or dosage is a decision the client makes with his or her physician.
Rather than dealing with treatment of disease, the Weigh For Wellness program focuses on wellness and prevention of illness through the use of medical nutrition therapy, nutrition counseling and natural nutritional therapies to achieve optimal health. These assessment tests are intended as a guide to developing an appropriate health-supportive program for me, and to monitor my progress in achieving my goals. As a licensed nutritionist and exercise physiologist, Victoria Goodwin MA RD LDN primarily educates and motivates clients to assume more personal responsibility for their health by adopting a healthy attitude, lifestyle, and diet.
I understand that Victoria Goodwin MA RD LDN may keep notes as a record of our work together. These notes document the topics discussed, interventions used, and treatment plan or any other considerations that may be helpful to reach your goals. Records will be stored in a secure location.
Medical records, personal information and history divulged in session to Victoria Goodwin MA RD LDN will be kept strictly confidential unless I consent to sharing my medical and nutritional information by way of a signed release.
While people generally experience greater health and wellness as a result of embracing a healthier attitude, lifestyle, and diet, Victoria Goodwin MA RD LDN does not promise or guarantee protection from future illness.
By signing below, you acknowledge that you understand that Victoria Goodwin MA RD LDN is a nutrition consultant and not a physician, and that you should see a doctor if you think you have a medical condition. Weight For You, LLC will not be held liable for failure to diagnose or treat an illness, nor will she be liable for failure to prevent future illness.This is a contract between Weight For You, LLC and myself. I understand that it is also a release of potential liability.
Additionally, you promise to give Victoria Goodwin MA RD LDN a complete and accurate account of any medical conditions that you may have and any medications that you are taking.
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