1:1 Initial Nutritional Consultation

Agreement of Participation and Confidentiality

Your signature below indicates your permission and willingness to participate in the following assessment, future interviews, and to consider the potential programs available and recommendations provided. This may include, but not limited to dietitian/therapist interviewed, counseling, medical nutrition therapy, and subsequent dietary/nutrition/exercise/health recommendations. All information and data discussed, written, typed, or communicated will be held strictly confidential between the patient and Vitality Nutrition professions. Your signature indicates that the information provided by you in all requested forms, assessments, and counseling sessions is accurate and current to the best of your ability. Vitality Nutrition commits to helping you reach your lifestyle goals; encouraging and motivating you to overcome obstacles; equipping you to make healthy lifestyle decisions and encouraging you to not five on yourself or your goals. You also acknowledge that Vitality Nutrition is not solely responsible for your complete healthcare, and you will let us know of any changes or concerns in your health while you are receiving counseling with us.

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