- 15 min15 minutes
Complimentary 15-minute introductory call. If you do not see a convenient time, please call 704-665-9688 and we will do our best to accommodate you.
INFORMED CONSENT FORM TERMS FOR NUTRITIONAL COUNSELING I am employing the nutrition counseling services of Rhya Pachin, RDN, LDN in order to obtain information and guidance about health factors within my own control (diet, nutrition, and related behaviors) in order to nourish and support my health and wellness. I understand that Rhya Pachin is a Registered Dietitian/Nutritionist and does not dispense medical advice nor prescribe treatment. Rather, she provides education to enhance my knowledge of health as it relates to foods, dietary supplements, and behaviors associated with eating. While nutritional and botanical support can be an important compliment to my medical care, I understand nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider. Nutritional evaluation or testing provided in counseling is not intended for the diagnosis of disease. Rather, these assessment tests are intended as a guide to developing an appropriate health-supportive program for me, and to monitor my progress in achieving my goals. I understand that Rhya Pachin, RDN, LDN will keep therapy notes as a record of our work together. These notes document the topics that we talk about, interventions used, and treatment plan or any other considerations that may be helpful to your work with me. Records will be stored in a secure location. Medical records, personal information and history divulged in session to Rhya Pachin, RDN, LDN will be kept strictly confidential unless I consent to sharing my medical and nutritional information by way of a signed release. I acknowledge that I have read and understand the HIPAA privacy agreement provided in hard copy form from Rhya Pachin, RDN, LDN. I agree to hold Rhya Pachin, RDN, LDN harmless for claims or damages in connection with our work together. This is a contract between myself and Rhya Pachin, RDN, LDN, and I understand that it is also a release of potential liability. I understand that Rhya Pachin, RDN, LDN has a 24-hour cancellation policy, and I am aware that I will be charged a $75 fee for a missed appointment if proper notice is not given (by phone or email). This same integrity is in effect for Rhya Pachin, RDN, LDN. Should she ever have to cancel within 24 hours of the appointment, your next follow up appointment will be reduced by $75. Payment is required at the time of service. Cash, check and major credit cards are accepted. Nutrition counseling services may be terminated at the discretion of Rhya Pachin, RDN, LDN if written notification is provided to a client 30 days in advance of final appointment. This will include a listing of referrals for continuity of care.
PO Box 77674 Charlotte NC 28271