Please read and sign below. 

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Consent for Care:

I give permission to the Registered Dietitian to provide nutrition assessments and a nutrition care plan as deemed appropriate based on my particular medical and health care needs.

 

I understand it is my responsibility to inform my doctor(s) and my dietitian of any adverse side effects or changes to my health or well-being that are related to change(s) in my diet, lifestyle, or physical activity so that immediate attention and adjustments can be made to optimize my overall health.

 

I understand and am informed that results from treatments may vary and are not guaranteed. In addition, I understand that my compliance with diet recommendations, prescribed exercises and lifestyle modification will increase the effectiveness of my care and enhance or maintain the results.

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I understand that I am in no way obligated to purchase the foods, products or run labs recommended by the Registered Dietitian. I am free to purchase products from any source that I may choose.

 

Communication:

My signature below gives the staff permission to email and leave messages on my voicemail containing non-protected information such as appointment scheduling.

 

Cancellation Policy:

I understand it is my responsibility to reschedule or cancel my appointment at least 48 hours in advance. If I do not reschedule or cancel my appointment within the required timeframe and/or do not attend a scheduled appointment, I agree to pay the full amount for the services that were scheduled to be provided. The credit card on file will be charged. If there is no card on file, a bill will be sent to the client’s home requesting payment within 30 days. After 30 days, 3% interest will be charged. If payment is still not made by Day 60, the bill may be sent to a collections agency.

 

Financial Policy:

ZEST Nutrition is a ‘fee-for-service’ office and is not contracted with any insurance companies. We require payment to be made at the time of service or prior to service. You are 100% responsible for all fees. Payment can be made by check or e-transfer. There is a $35 fee for any returned check. Credit and debit cards are accepted, but have a 3% charge per transaction. Flexible Spending Account (FSA) cards and Venmo are accepted with no fee.   

 

I understand that any expenses incurred with ZEST Nutrition for myself or any of my minor dependents are my responsibility and not that of any other person or insurance group. I understand that payment is due in full at the time of service.

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