Consent Form — Devon Guy - Calgary Dietitian and Nutrition Services

Client Consent FOrm

All efforts are made to protect the client and avoid undue invasion of privacy. Any personal health information in the dietitian’s custody or control must be protected from theft, loss, unauthorized use or disclosure. All information obtained or disclosed in an assessment or counselling session is strictly confidential and will not be revealed to any other persons without the client’s authorized consent.

Name

First Name

Last Name

Electronic Communication

When using virtual or telephone communications with patients/clients, registered dietitians take any and all reasonable steps to ensure that the personal health information of clients is protected. Medical records and personal information and history disclosed in session to a dietitian will be kept confidential, unless consent to sharing medical information is obtained in writing. If nutritional advice provided through web-supported platforms (including but not limited to Skype and FaceTime) is requested, clients must understand and accept that internet associated activities are inherently at risk for a breach of personal information. The client understands that if they schedule a web-based session that this implies consent and understanding of these risks. Check the box(es) below if you agree to the following lines of communication:

Text Message

Telephone

Video Conferencing (Zoom, FaceTime, Skype)

Date

YYYY

Consent to Evaluate and Treat a Minor

Leave the following blank if not applicable

Minor's Name

First Name

Last Name

Guardian Name

First Name

Last Name

Client Consent FOrm

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