INFORMED CONSENT FORM & TERMS FOR NUTRITIONAL COUNSELLING
Consent for Nutritional Counselling
I hereby request and consent to Gazelle Nutrition Lab (Ashley Leone, RD) providing Nutrition Counselling to myself or the client for which I am legally responsible. I understand that the consult will provide information and guidance about my diet, nutrition, and lifestyle.
I understand that Ashley Leone is a Registered Dietitian and she does not dispense medical advice, nor will she diagnose or treat any medical condition. Methods of nutritional evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessments are intended as a guide to enhancing my nutritional health and supporting the achievement of my athletic goals.
Ashley will provide nutritional support and nutrition education that relates to athletic performance and, or, for general healthy eating. Ashley may also provide nutritional counselling for an already diagnosed nutritionally related condition.
Confidentiality and Consent for Web-Based Counselling
Medical records and personal information and history divulged in session to Gazelle Nutrition will be kept confidential, unless I consent to sharing my medical information. Further, if I would like nutritional advice provided through web-supported platforms (including but not limited to Skype, Google Hangouts, and FaceTime) I understand and accept that Internet associated activities are inherently at risk for a breach of personal information. I understand that if I schedule a web-based session that this implies consent and understanding of these risks.
Consent for Personal Information:
I accept that it will be necessary for Ashley Leone, RD, to collect personal, health and lifestyle information, e.g. home telephone, address, way of eating, etc.
Use, Disclosure, and Retention of Information
I understand that only information relevant to the provision of services for my nutritional management will be collected, and that this information will be retained in my client health record for ten years following the last date of service (or ten years following my eighteenth birthday, whichever is longer). I give permission for this information to be shared with my primary care physician.
I understand that I may review the information in my file for accuracy and currency. If I disagree with the information, I accept that either a correction will be made or my disagreement will also be noted.
Further, I understand that I may withdraw consent for any or all of the above at any time and that I should do so in writing.
Consent for Cost of Services
Individual Consultation $150.00/hour
The initial appointment is 45 minutes long and consists of a nutrition assessment and a personalized meal plan that suits the individual’s needs, food habits, goals, and lifestyle.
Individual Follow-Up $70.00/ half hour
This is a 20-30 minute appointment to assess whether you are meeting your nutrition goals and to address any obstacles you have encountered. We will also assess what further changes you can make to achieve your optimal health.
Basic Package $200.00
Includes one (1) initial appointment (45 minutes), one (1) computerized analysis of a 3-day food record. Choice of personalized one-day meal plan OR training nutrition plan OR race day nutrition plan. 50% discount on subsequent one-day, training or race day plans.
Basic Plus Package $315.00
Includes one (1) initial appointment (45 minutes), one (1) computerized analysis of a 3-day food record. Two 20-minute follow-up appointments. Choice of personalized one-day meal plan OR training nutrition plan OR race day nutrition plan. 50% discount on subsequent one-day, training or race day plans.
Supreme Package $440.00
One initial 45-minute session. Two 20-minute follow-up appointments. One computerized diet analysis of a 3-day food record. Snack list. 3 goal-focused nutrition plans for sports or healthy eating: Either Sports plans get- one-day meal plan + training nutrition plan + race day nutrition plan; OR Healthy eating plans get- one-day meal plan + eating out plan + travelling plan. Plus, body composition analysis.
Ultimate Package $750.00
The Supreme Package + 7-day meal plan with recipes and grocery list.
Nutrigenomics Package $425.00
This package includes a sports nutrigenomics test or regular nutrigenomics test in addition to a 30-minute counselling session.
I understand that I must provide 24 hours notice of cancellation or rescheduling. I understand that failure to show, or cancellation with less than 24 hours notice, will result in a charge of 100% of the service price.