INFORMED CONSENT FORM - NUTRITIONAL THERAPY PROGRAMME
I acknowledge that the purpose of this programme is to help me improve my health, wellness, and lifestyle.
I am employing the services of Valeriya Simonova so that I can obtain information and guidance about health factors within my own control (such as diet, hydration, lifestyle, wellness, and various other related behaviours) in order to help support my health and wellness.
I understand that she is a Nutritionist and does not dispense medical advice nor prescribe treatment. Rather, she provides education to enhance my knowledge of health as it relates to food consumption, hydration, lifestyle, and related activities. While nutritional support can be an important complement to my medical care, I understand that a nutritional therapy programme is not a substitute for the diagnosis, treatment, or care of a disease, illness, or injury by a medical provider.
Nutritional evaluations and lifestyle assessments are not intended for the diagnoses of disease. Rather, these are intended as a guide for the development of a nutritional programme and used to monitor my progress in achieving my health and wellness goals.
I understand that Valeriya Simonova will keep all documents related to me (including, but not limited to, assessments, food diaries, forms, worksheets, audio, transcripts, video, or images) and any notes that relate to me, as a record of our work together. I understand that records may also document the topics that we talk about, my progress, plans discussed, or any other considerations that may be helpful to my health and wellness. Records will be stored in a secure location.
Medical records, personal information and health history divulged to Valeriya Simonova in or out of session, will be kept strictly confidential unless I consent to sharing this information by way of a signed release.
I understand that every person is unique and it is not possible to determine in advance how my system will react to certain foods, drinks, supplements, or dietary products that may be suggested to me from time to time. I agree that it may be necessary to adjust my plan from time to time or until my body can begin to properly accept nutritional changes. I accept that it is my responsibility and decision to use or disregard nutritional, exercise, and lifestyle guidelines. It is also my responsibility to hydrate well, get plenty of rest, and learn about nutrition.
I agree to hold Valeriya Simonova harmless for claims or damages in connection with our work together under the terms of this consent form. I understand that this consent form is also a release of her liability. I accept that the advice under this programme is not a guarantee for health improvements or for reaching my health goals, and that I should not use food products or supplements as a substitute for medical treatment or a varied diet.
All components of the programme have been explained to me and demonstrated but I should feel free to ask any questions I may have. I agree that I will inform Valeriya Simonova if there is any reason why I should not continue with the programme; for example, an illness or an injury that require medical advice. If, at any time, I feel undue pain or excessive discomfort, I will stop the programme undertakings immediately and inform Valeriya Simonova of my symptoms. I am at all times responsible for seeking medical advice where appropriate.
I understand I am free to withdraw from the programme at any time I wish. I agree to take part in the programme described to me by Valeriya Simonova. The nature, purpose, risks, and benefits have been explained to me and I understand what is required of me and that I may withdraw at any time. The services may also be terminated at the discretion of Valeriya Simonova with sufficient notice.
I understand the intellectual property rights and privacy of all of the materials and information provided to me during this programme. I agree to use the session handouts, worksheets, and questionnaires for my own personal (noncommercial) purposes only and that I will not share, copy, or distribute them to third parties.