Elevate Client Intake Consent + Confidentiality Agreement

Please read the following, and then fill out the corresponding form below

By filling out this form, I hereby grant permission for the Registered Dietitian to collect personal information including my name, date of birth, phone number, email address, medical history, medications, supplements, food allergies/intolerances, food intake records, food or nutrition-related concerns, lab values accessed through E-Health Saskatchewan, and any other information pertinent to the nutrition service provided. This information will be used for nutrition assessment, follow up counselling and coaching. Further, I consent to communication in the form of email or phone for consultation and resource sharing, and to videoconferencing mediums for virtual counselling and personal training.

I also grant permission for the dietitian to correspond with my physician(s) or pertinent health care provider(s) to obtain or share information relevant to my nutrition treatment and counselling, as needed, at any time during my care and consultation with ELEVATE Nutrition and Wellness.

I am aware that my personal health information will be retained for ten years following the last date of service (or ten years following my eighteenth birthday, whichever is longer) and then destroyed in compliance with provincial privacy legislation- HIPA. I also understand that I have the right to view the health information in my file and to review the privacy policies of ELEVATE Nutrition and Wellness.

Payment

The fee schedule for services has been explained to me and I understand that all consultation services are payable by electronic transfer, cash or credit card (VISA or Mastercard) to ELEVATE Nutrition and Wellness due at time of the initial consultation. Note, GST and PST are not added to dietitian services. Receipts are issued to indicate each nutrition consultation session. Receipts intended for insurance reimbursement purposes cannot be issued prior to consultation services being received. Packages are redeemable twelve months from the date of purchase and are non-refundable.

Appointment Cancellation

I understand that I need to provide 24 hours’ notice for cancellation or to reschedule an appointment. Failure to attend a scheduled appointment or provide a cancellation within 24 hours is subject to a cancellation fee.