INFORMED CONSENT FORM & TERMS FOR NUTRITIONAL COUNSELING

I give consent to Jennifer Reilly, RD to provide Nutrition Counseling to
myself or the client for which I am legally responsible. The consult will provide information and guidance about health factors within my own control: my diet, nutrition, and lifestyle.

I understand that Jennifer Reilly is a Registered Dietitian—not a medical physician—and does not dispense medical advice, nor will she diagnose or treat any medical condition, but will provide nutritional support and nutrition education for an already diagnosed condition. She provides education to enhance my knowledge of health through the use of whole foods, dietary supplements, and emotional awareness.

While food and nutrition choices can be an important complement to my medical care, I understand these services are not a substitute for medical care. Methods of nutritional evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessment tests are intended as a guide to developing an appropriate health-supportive program for me, and to monitor my progress in achieving my goals.

Medical records and personal information and history divulged in session with Jennifer Reilly will be kept confidential, unless I consent to sharing my medical information. I agree to hold Jennifer Reilly, RD harmless for claims or damages in connection with our work together. This is a contract between myself and Jennifer Reilly, RD and I understand that it is also a release of potential liability.