Memorial Hospital Self-Pay Registered Dietitian Services Waiver
The information provided is designed for and solely intended to be suggestions, which may voluntarily be implemented by the person whose signature appears below.
Memorial Hospital’s Health & Wellness Self-Pay Services include the following packages, but is not limited to:
Nutrition Coaching 1:1
Lactation Services
Nutrition Coaching for Groups
Tanita Scale
Meal Plan Creation
Pantry Makeovers
Grocery Store Tours
Use of any nutrition information provided is voluntary and each user is solely responsible for their voluntary choice to implement the suggestions. It is the sole responsibility of the client to provide complete and accurate information.
The Registered Dietitian is not licensed to diagnose a medical condition or illness.
I have agreed to participate voluntarily in a nutrition coaching program under the guidance of Memorial Hospital’s Registered Dietitians.
I have volunteered to participate under the direction of a Memorial Hospital Registered Dietitian, which will include, but may not be limited to nutritional planning. In consideration of my Registered Dietitian’s agreement to assist me, I do here and forever release and discharge and hereby hold harmless the Registered Dietitian of Memorial Hospital, Memorial Hospital, and his/ her respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in any nutrition program including any injuries resulting therefrom.
I acknowledge as the client participating in a Memorial Hospital’s Health & Wellness Self-Pay Service, information will not be documented in my medical record or communicated with my medical provider.
I recognize that specific foods may create allergic and possible fatal reactions. I have, therefore, specified any food allergies/sensitivities I am aware of in the Health History & Lifestyle Questionnaire. I am aware that specific foods may interact with certain medications. I have, therefore, specified all prescription and OTC medications on the Health History & Lifestyle Questionnaire and have discussed the side effects of all my medications with my doctor or pharmacist.
Client/Registered Dietitian Agreement
By signing this agreement, I am agreeing to the following terms of Memorial Hospital:
Payment:
- Payment is expected electronically prior to appointment for the client's specified offering.
- Registered Dietitian sessions expire one year from the date of purchase.
- Memorial Hospital Self-Pay Services are nonrefundable.
Appointment:
- Patient’s completed Health History & Lifestyle Questionnaire must be emailed or dropped off 72 hours prior to scheduled initial session.
- Registered Dietitian and clients are expected to confirm meeting times so there is no misunderstanding. The Health & Wellness Administrative Assistant will support with scheduling.
- Individual appointments are scheduled for a specific time. In the event you cannot make your scheduled appointment we kindly ask you to provide 24-hour advance notice.
- Two missed appointments will result in losing purchased service and client will need to repurchase service if desired.
- I understand that the staff and/or instructor will not be held responsible for any injuries, illnesses, or expenses from my participation, especially if I have neglected to disclose known medical condition or similar information about myself that might affect my ability to participate.
In signing below, I agree to ALL the above conditions as well as other policies of the facility.