Informed Consent & Disclaimer

 

Before you choose to use the services of a Nutritional Therapist, please read the following information FULLY AND CAREFULLY.

Nutritional Therapy Informed Consent and Disclaimer

Enter the name of your Nutritional Therapist here *
Enter the name of your Nutritional Therapist here
Example: Serina Vassar (note, do NOT enter your own name)
GOAL
GOAL: Our basic goal is to encourage people to become knowledgeable about and responsible for their own health, and to bring it to a personal optimum level. Nutritional therapy is designed to improve your health, but is not designed to treat any specific disease or medical condition. Reaching the goal of optimum health, absent other non-nutritional complicating factors, requires a sincere commitment from you, possible lifestyle changes, and a positive attitude. A Nutritional Therapist is trained to evaluate your nutritional needs and make recommendations of dietary change and nutritional supplements. A Nutritional Therapist is not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis. Since every human being is unique, we cannot guarantee any specific result from our programs. *
HEALTH CONCERNS
HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. A Nutritional Therapist is not a substitute for your family physician or other appropriate healthcare provider. A Nutritional Therapist is not trained nor licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases. *
HEALTH CONCERNS: If you are under the care of another healthcare provider, it is important that you contact your other healthcare providers and alert them to your use of nutritional supplements. Nutritional therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program. *
HEALTH CONCERNS: If you are using medications of any kind, you are required to alert the Nutritional Therapist to such use, as well as to discuss any potential interactions between medications and nutritional products with your pharmacist. *
HEALTH CONCERNS: If you have any physical or emotional reaction to nutritional supplement, discontinue their use immediately, and contact your Nutritional Therapist to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the therapy. *
COMMUNICATION
COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the supplements you need. It is sometimes necessary to adjust your program as we proceed until your body can begin to properly accept products geared to correct the imbalance. It is your responsibility to do your part by using your nutrition guidelines, exercise your body and mind sufficiently to bring your emotions into a positive balance, eat a proper diet, get plenty of rest, and learn about nutrition. You must stay in contact with the Nutritional Therapist so we can let you know what is happening and the best course of action. *
COMMUNICATION: You should request your other healthcare provider, if any, to feel free to contact the Nutritional Therapist for answers to any questions they may have regarding nutritional therapy. *
LICENSURE
LICENSURE: A Nutritional Therapist is not licensed or certified by any state. However, a Nutritional Therapy Practitioner(TM) is trained by the Nutritional Therapy Association, Inc.® which provides a certificate of completion to students who have successfully met all course requirements, including a written and practical exam. A license to practice Nutritional Therapy is not required in some states. Laws and regulations regarding certification and licensure requirements differ from state to state. *
NUTRITIONAL THERAPY MAY NOT BE COVERED BY INSURANCE AND ALL COSTS ARE THE SOLE RESPONSIBILITY OF THE CLIENT *
AGREEMENT AND RELEASE OF LIABILITY
AGREEMENT AND RELEASE OF LIABILITY: The health and nutritional information you receive from Serina Vassar, NTP of Wise Bear Functional Nutrition, LLC, whether given by phone, in person at your home, in the Wise Bear Functional Nutrition, LLC office, through lectures, workshops, brochures, emails, website, or newsletters is not intended to diagnose, prescribe, treat, cure, alleviate, prevent or care for any disease in any way. It consists of combined information from many educational sources and points of view to help you make informed decisions regarding your desired level of health. The sources behind this information include: modern medicine, ancient Chinese medicine, naturopathic medicine and the therapist’s personal research, study, educational materials from the Nutritional Therapy Association, Ulan Nutritional Systems, and life observation as well as patient results and experiences. Anyone deciding to act upon any information mentioned during a consultation shall assume full responsibility for any effects of their actions. There are risks and unforeseen results associated with any change of diet and lifestyle. It is not recommended that you apply these changes unless you are willing to assume full responsibility for the risks you choose to take. If you choose to implement dietary and lifestyle changes without consulting your physician, which is your constitutional right, you are, in effect, prescribing for yourself. When in doubt of the appropriateness of any treatment, whether recommended to you by a clinician/ practitioner or by your own intuition, please consult a physician. Consultation information should not be used as a substitute for a physician’s advice. It is our hope that you do choose a physician who realizes the importance of a healthy diet and lifestyle choices in correcting imbalances in the body and who has experience in treating immune disorders and other health imbalances. Please be aware that you have the right to make your own health decisions based on any information made available to you. YOU are the driving force in guiding yourself on a path to health! *
ACKNOWLEDGEMENT
ACKNOWLEDGEMENT: I accept the terms and conditions of this disclaimer. I acknowledge that any and all information given to me by Serina Vassar, NTP of Wise Bear Functional Nutrition, LLC is to be used for educational purposes only. I also acknowledge that neither Wise Bear Functional Nutrition, LLC nor Serina Vassar, NTP claim to be medical doctors and will not prescribe for or diagnose, treat, prevent, alleviate or cure any disease or condition. *
ACKNOWLEDGEMENT: If I experience any changes in my health or current medications, I will immediately communicate this information to Wise Bear Functional Nutrition, LLC. I further acknowledge that I am fully responsible for any decisions and/or changes I make regarding my health and I will not hold Wise Bear Functional Nutrition, LLC or Serina Vassar, NTP liable for my own decisions, any results of my decisions or of any natural treatment or advice I may receive. *
ACKNOWLEDGEMENT: I understand that Muscle Response Testing and Nutritional Therapy are safe, non- invasive, natural methods of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalances in these areas could cause or contribute to various health problems. I understand that Muscle Response Testing and Nutritional Therapy are not a methods for “Diagnosing” or “Treating” any disease including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated. No promise or guarantee has been made regarding the results of Muscle Response Testing, Nutritional Therapy, or any natural health, nutritional or dietary programs recommended, but rather I understand that Muscle Response Testing and Nutritional Therapy are a means by which the body’s natural reflexes can be used as an aid to determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health. *
ACKNOWLEDGEMENT: In consideration of being allowed to participate in programs, modalities, and activities of Wise Bear Functional Nutrition, LLC and to use its facility in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge Wise Bear Functional Nutrition, LLC and its directors, officers, agents, employees, representatives, successors and assigns, administrators, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from my participation in any activities or my use of equipment or machinery. I do also hereby release all of these mentioned and any others acting upon their behalf from any responsibility or liability from any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of Wise Bear Functional Nutrition, LLC. I understand that Carone Chiropractic Center, and Nicholas Carone, DC is a separate entity and would not liable for any legal action that may be incurred by Wise Bear Functional Nutrition, LLC, Serina Vassar, NTP. *
ACKNOWLEDGEMENT: I have read and understand the foregoing. Intending to be legally bound, I hereby release Wise Bear Functional Nutrition, LLC from any liability, including for negligence, regarding my health matters and my participation in Muscle Response Testing, Nutritional Therapy, or any other program. This release applies to all subsequent visits for programs, modalities and activities at Wise Bear Functional Nutrition, LLC. By my/our signature(s) below, I/we confirm that I/we have read and fully understand the above disclaimer, are in complete agreement thereto and do freely and without duress sign and consent to all terms contained herein: *
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