CONSENT FORM & TERMS FOR NUTRITIONAL COUNSELING
I am employing the consulting services of University Nutrition Counseling by Tara Tousi, M.S., R.D. so that I can receive information and guidance to enhance my knowledge of health as it relates to the foods I eat and my behaviors associated with eating.
I acknowledge that Tara Tousi, M.S., R.D. is a Registered and Licensed Dietitian/Nutritionist and does not dispense medical advice or diagnose or treat any medical condition.
I am aware that while food and nutrition can be complementary to medical care and an important part of my health and healing, my work with Tara Tousi, M.S., R.D. is not a substitute for diagnosis, treatment, or care by a medical provider.
I am aware that Tara Tousi, M.S., R.D. will keep notes as a record of our work together in order to document the topics we discuss, treatment plans, and other considerations that support me as I learn to nourish my body and optimize my health and wellbeing.
I recognize that any methods of nutritional evaluation or testing provided to me by Tara Tousi, M.S., R.D. are not intended to diagnose disease but instead are intended as guidance and support as I learn new strategies for optimizing my health through nutrition. These assessments are intended to help me monitor my progress in achieving my nutritional goals.
I understand that my medical records and personal information will be kept strictly confidential unless I consent to sharing my medical information or Tara Tousi, M.S., R.D. is compelled to share it by law.
I understand that I am responsible for discussing any dietary changes with my primary care physician. I also acknowledge that I should not discontinue any prescription medications without first consulting my primary care physician.
I realize that it is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my treatment plan with my physician and/ or Tara Tousi, M.S., R.D. I will not hold Tara Tousi, M.S., R.D. responsible for any complications that result from my failure to comply.
I agree to hold Tara Tousi, M.S., R.D. harmless for claims or damages in connection with our work together. This is a contract between myself and Tara Tousi, M.S., R.D., and I understand that it is also a release of potential liability.
I understand that Tara Tousi, M.S., R.D. has a 24-hour cancellation policy. I am aware that I will be charged an hour’s fee for a missed appointment if proper notice is not given. Proper notice may be given by phone or email.