Program Informed Consent
Please read and sign below.
This form is a legal document that explains the risks the client assumes when partaking in service(s) and/or a wellness program with Michelle Baglio / Optimal Nutrition and Health, (hereafter referred to as Optimal Nutrition and Health). It is important that the client read and understand it completely. After doing so, the client is asked to please complete the bottom portion to confirm that he/she has read, fully understand, and agree to all of the statements and agreements.
The client gives consent to Optimal Nutrition and Health to provide nutrition and health coaching to him/herself or the individual for which he/she is legally responsible. The client understands that Michelle Baglio is a registered dietitian (not a licensed medical physician). She does not claim to treat, cure, or diagnose any specific disease or medical condition.
Upon purchasing a Wellness Program, please be aware that the use of such program is for the time specified. Your initial meeting for a program must be used within 2 weeks of purchasing a program and this begins the time-frame indicated for the program purchased (i.e., 28-days, 12 weeks, 6 months). If you are unable to complete all meetings in the time specified, you will forfeit those meetings you were unable to attend or reschedule within the time specified. Should you need to reschedule a meeting, please do so at least 24-hours prior to your scheduled meeting. Otherwise, you may forfeit that meeting. If you choose to make installment payments on your program, you will be required to pay at the indicated weeks. If a payment is not received in a timely manner, you may forfeit remaining meetings until such payment is received.
The nutrition and health advice given by Optimal Nutrition and Health is solely based on the information provided by the client. It is the client’s responsibility to provide complete and accurate information. Any misinformation, inaccurate or omitted information may affect the assessment and/ or recommendations given. Any misrepresented information is the client’s responsibility entirely and Optimal Nutrition and Health will not be liable. All personal information the client shares with Optimal Nutrition and Health will be kept strictly confidential, unless the client consents to sharing it.
The services provided by Optimal Nutrition and Health are intended to help the client meet his/ her nutrition and health goals and may complement the care of other healthcare providers but are not a substitute for medical care. Any assessment methods that the client takes part in will serve as a guide to help him/her in the development of an appropriate nutrition and health program tailored to his/her individual needs and help him/her monitor progress in meeting these goals. It is the client’s responsibility to decide which dietary and lifestyle changes to follow and to discuss any potential risks and benefits of these changes with Optimal Nutrition and Health and the client’s other healthcare provider(s). It is important that the client keep the other member(s) of his/her healthcare team informed of any changes to the client’s nutrition and health program as a result of working with Optimal Nutrition and Health as well. The client understands that Optimal Nutrition and Health does not have control over how he/she may use the information provided and, therefore, Optimal Nutrition and Health will not be held responsible for the client’s actions.
Every client is individual and it is not possible to determine in advance how he/she will progress when starting a wellness program. It is sometimes necessary to adjust the client’s program as a result and it is important that he/she stays in contact with Optimal Nutrition and Health regarding his/her progress and any concerns or questions he/she may have in order to proceed with the best course of action. The client acknowledges and understands that no warranties or representations have been made to him/her regarding the results he/she will achieve from this wellness program. The client understands that results are individual and may vary.
In addition, the client agrees that all of the information he/she receives from Optimal Nutrition and Health is for the client’s personal use and may be shared only with his/her immediate family and healthcare team. No part of this information may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means including, but not limited to, electronic, mechanical, photocopy, recording without the prior written permission of Optimal Nutrition and Health. The client also agrees that he/she will not participate in or encourage electronic piracy of copyrightable materials.
Lastly, the client may be in contact with Optimal Nutrition and Health using email communication to relay such items as appointment times and for brief check-ins to discuss progress. Because it is not possible to guarantee the security of this form of communication, it is generally not recommended that the client share other personal health information. However, it is the decision of the client what to include in his/her email communication and he/she takes full responsibility for the security of this information. As part of the program, the client will also receive the Optimal Nutrition and Health email newsletter; the client may choose to unsubscribe to this at any time during or following the program.
The client hereby affirms consent and agreement to the above statements set forth in this form and agrees to partake in the service(s) and/or program purchased with Optimal Nutrition and Health by his/her own free will.
This form is a legal document that explains the risks the client assumes when partaking in service(s) and/or a wellness program with Michelle Baglio / Optimal Nutrition and Health, (hereafter referred to as Optimal Nutrition and Health). It is important that the client read and understand it completely. After doing so, the client is asked to please complete the bottom portion to confirm that he/she has read, fully understand, and agree to all of the statements and agreements.
The client gives consent to Optimal Nutrition and Health to provide nutrition and health coaching to him/herself or the individual for which he/she is legally responsible. The client understands that Michelle Baglio is a registered dietitian (not a licensed medical physician). She does not claim to treat, cure, or diagnose any specific disease or medical condition.
Upon purchasing a Wellness Program, please be aware that the use of such program is for the time specified. Your initial meeting for a program must be used within 2 weeks of purchasing a program and this begins the time-frame indicated for the program purchased (i.e., 28-days, 12 weeks, 6 months). If you are unable to complete all meetings in the time specified, you will forfeit those meetings you were unable to attend or reschedule within the time specified. Should you need to reschedule a meeting, please do so at least 24-hours prior to your scheduled meeting. Otherwise, you may forfeit that meeting. If you choose to make installment payments on your program, you will be required to pay at the indicated weeks. If a payment is not received in a timely manner, you may forfeit remaining meetings until such payment is received.
The nutrition and health advice given by Optimal Nutrition and Health is solely based on the information provided by the client. It is the client’s responsibility to provide complete and accurate information. Any misinformation, inaccurate or omitted information may affect the assessment and/ or recommendations given. Any misrepresented information is the client’s responsibility entirely and Optimal Nutrition and Health will not be liable. All personal information the client shares with Optimal Nutrition and Health will be kept strictly confidential, unless the client consents to sharing it.
The services provided by Optimal Nutrition and Health are intended to help the client meet his/ her nutrition and health goals and may complement the care of other healthcare providers but are not a substitute for medical care. Any assessment methods that the client takes part in will serve as a guide to help him/her in the development of an appropriate nutrition and health program tailored to his/her individual needs and help him/her monitor progress in meeting these goals. It is the client’s responsibility to decide which dietary and lifestyle changes to follow and to discuss any potential risks and benefits of these changes with Optimal Nutrition and Health and the client’s other healthcare provider(s). It is important that the client keep the other member(s) of his/her healthcare team informed of any changes to the client’s nutrition and health program as a result of working with Optimal Nutrition and Health as well. The client understands that Optimal Nutrition and Health does not have control over how he/she may use the information provided and, therefore, Optimal Nutrition and Health will not be held responsible for the client’s actions.
Every client is individual and it is not possible to determine in advance how he/she will progress when starting a wellness program. It is sometimes necessary to adjust the client’s program as a result and it is important that he/she stays in contact with Optimal Nutrition and Health regarding his/her progress and any concerns or questions he/she may have in order to proceed with the best course of action. The client acknowledges and understands that no warranties or representations have been made to him/her regarding the results he/she will achieve from this wellness program. The client understands that results are individual and may vary.
In addition, the client agrees that all of the information he/she receives from Optimal Nutrition and Health is for the client’s personal use and may be shared only with his/her immediate family and healthcare team. No part of this information may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means including, but not limited to, electronic, mechanical, photocopy, recording without the prior written permission of Optimal Nutrition and Health. The client also agrees that he/she will not participate in or encourage electronic piracy of copyrightable materials.
Lastly, the client may be in contact with Optimal Nutrition and Health using email communication to relay such items as appointment times and for brief check-ins to discuss progress. Because it is not possible to guarantee the security of this form of communication, it is generally not recommended that the client share other personal health information. However, it is the decision of the client what to include in his/her email communication and he/she takes full responsibility for the security of this information. As part of the program, the client will also receive the Optimal Nutrition and Health email newsletter; the client may choose to unsubscribe to this at any time during or following the program.
The client hereby affirms consent and agreement to the above statements set forth in this form and agrees to partake in the service(s) and/or program purchased with Optimal Nutrition and Health by his/her own free will.