General Consent To Treatment
I give consent to Healing Plate to provide Nutrition Counseling to myself or the client for which I am legally responsible.
I understand the consult will provide information and guidance about health factors within my own control: my diet, nutrition, and lifestyle. I understand that the nutrition practitioners I am seeing are nutritionists and not medical physicians. Thus, they will not dispense medical advice and will not diagnose medical conditions. The nutrition practitioners will provide nutritional support and nutrition education for an already diagnosed condition and/or to enhance my nutritional health.
While nutritional support can be an important complement to my health and disease management, I understand these services are not a substitute for medical care. Methods of nutrition evaluation or testing made available to me are not intended to diagnose disease. Rather, 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.
Confidentiality and Consent for Web-Based Counseling Medical records and personal information and history divulged in counseling sessions with Healing Plate will be kept confidential unless I consent to share my medical information.
Telehealth Consent-
If I would like nutritional advice provided through web-supported platforms I understand and accept that Internet associated activities are inherently at risk for a breach of personal information. I understand that if I schedule a web-based session that this implies consent and understanding of these risks.
In Addition,
1. I hereby authorize Healing Plate Nutrition to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.
2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
4. I understand that my current insurance does not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.
5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
Cancellation Policy
I understand that I must provide 24 hours' notice of cancellation or rescheduling. I understand that failure to show, or cancellation with less than 24 hours' notice, will result in a charge of 50% of the service price.
I have read this consent form and terms contained herein carefully. I understand the terms of this form fully and voluntarily agree to be bound by them.
I hereby release and discharge, indemnify, and hold harmless Healing Plate, the Regents of Healing Plate, their officers, agents, employees, and persons acting on their behalf, from all claims, demands, costs and expenses, and causes of action, either in law or equity arising out of or in any way connected to services I receive from Healing Plate.