Patient Privacy and Consent Form

The Lifestyle Nutritionist understands the importance of protecting and using your personal information appropriately and responsibly. We are aware of the sensitive nature of the information you have disclosed to us and assure you that the personal information you provide to us is private and confidential. This document outlines how The Lifestyle Nutritionist collects, uses and discloses personal patient information.

The Lifestyle Nutritionist will collect, use and disclose information about you in accordance with our Privacy Policy for the following purposes:

• In delivering healthcare and healthcare services:
  • To assess your health needs, deliver safe and effective client/patient care, advise you of your treatment options for follow-up treatment, care and billing.
  • To communicate with other relevant health-care providers.
  • In the event of an emergency, we may disclose your information to notify or assist in notifying a family member or emergency contact person as specified by you.
  • For teaching, demonstration and research purposes on an anonymous basis.
  • To enable us to contact you, establish and maintain communication with you. This may include distributing healthcare information, booking and confirming appointments, and via client/patient educational newsletters. We may contact you by telephone or email using the phone number(s) and email address as provided by you.

•  In processing financial transactions:
  • For accounting purposes and to complete and submit insurance claims (eg. private health insurance rebates) and other third-party adjudication and payment.
  • To invoice for goods and services, process credit card payments and collect unpaid accounts.

•  In complying with the law and regulatory standards:
  • To comply with legal and regulatory requirements, such as, but not limited to, reporting child abuse or neglect, reporting problems with products or reactions to medications and reporting disease or infection exposure to public authorities.

Your health information rights

• You have the right to:
  • Request restrictions on certain uses and disclosures of your health information.
  • Access your health information.

The Lifestyle Nutritionist is not required to agree to requests made to amend or restrict the use of your personal information if it is in conflict with legal and professional regulatory requirements or in conflict with the clinic’s ability to deliver safe healthcare.

By accepting this Privacy and Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed.

The Lifestyle Nutritionist will not under any circumstance supply your confidential medical and personal information to any third parties unless required by law or consented by you. If a new purpose or request arises for the use and/or disclosure of your personal information we will seek your consent in advance. You may withdraw your consent for use or disclosure of your personal information, and will explain the reasons for such a decision.

Disclaimer
Even the gentlest therapies may cause complications in certain physiological conditions. This depends greatly on the individual and the extent of the illness. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease.
It is very important, therefore, that you inform your Nutritionist immediately of any disease that you are suffering from as well as any supplements and medications (prescription or over-the-counter) that you are taking. If you are pregnant, suspect you are pregnant, or you are breastfeeding, advise your Nutritionist immediately.

In order to clarify our position as health care practitioners, and our mutual responsibilities in your health care, it is important that you acknowledge that:

• Nutritionists are not Medical Doctors and that we use non-invasive, natural methods of assessment and treatment of body dysfunctions.
• Treatment and/or referral to other health practitioners is based upon the assessment of your health revealed through personal history, physical examination, laboratory testing and other appropriate methods of evaluation.
• The ultimate responsibility for your health care is your own, and that we are here to support you in this. We reserve the right to discontinue our services where it is apparent that your expectations and what we provide are not in agreement.
• The Nutritionist will answer any questions to the best of their ability. I understand that results are not guaranteed. I do not expect my Nutritionist to be able to anticipate all risks and complications, such as allergic reactions to supplements. I will rely on my Nutritionist to exercise judgment during the course of the procedure, which they feel at that time is in my best interests based on the facts then known.

I understand this consent form is to cover the entire course of my treatments. I understand that I am free to withdraw my consent and to discontinue participation in these treatments at any time.

I acknowledge that I have read and understood the conditions of The Lifestyle Nutritionist and consent to being consulted by Nutritionist Rebecca Price with regards to my health care. Furthermore, I agree not to hold Rebecca Price liable for any costs or damages related to the services provided other than for wilful misconduct or gross negligence.

I understand this consent agreement and have executed it freely and willingly.