Name

First Name

Last Name

Current Dietitian/Provider Name:

I request the dietitian hired provide nutritional counseling & related services as may be prescribed. I acknowledge nutritional counseling is not an exact science and no guarantees have been made as to the results of the treatment herby authorized.

Agree

I acknowledge the dietitian hired may communicate via phone, text, and email. I understand I may revoke, in writing, my consent to allow the dietitian to release this information at any time, except to the extent the action will have been already released.

Agree

I understand I'm not obligated to enter into this consent electronically and I have a right to conduct this consent in paper format if I wish. By clicking "Agree" button below, I affirmatively consent to conduct this release in electronic format.

Agree

The purpose of this disclosure is coordination of care, legal proceedings, or other situation communicated.

Agree

This document authorizes the dietitian hired to disclose and receive information concerning the patient and the patient's treatment to the following person(s):

Agree

Physician Name, Email & Phone Number:

Psychiatrist Name Email, & Phone Number:

Therapist Name, Email, & Phone Number:

Treatment Center Name & Phone Number

Dietitian Name, Email, & Phone Number

Family or Significant Other Name, Email, & Phone Number:

Other Name, Email, & Phone Number

I consent to the use of an e-signature to authenticate this release of confidential information in electronic form. I understand and agree the practice will rely on my e-signature to process and effect this consent.

Agree

Please type your name below in agreement with this policy *