Patient Consent Form

Please fill out this patient consent form before your first appointment. If you have not had an appointment in 12 months, please resubmit.

If you have any questions or concerns, please reach out - carmen@extravegnutrition.com.au

Extra Veg Nutrition - Patient Consent Form

Please fill out this form as best you can before your consult. Personal information only relevant to the services provided by Extra Veg Nutrition is collected. All personal information provided will be treated with complete confidentiality. You can access our Privacy Policy and Cancellation Policy through our website at www.extravegnutrition.com.au

Full Name

Phone

Birthday

Day

Month

Year

List your main health goals/focus/concerns/issues?

Do you have a primary healthcare practitioner? Please provide their name and clinic name.

Declaration

I give consent to be treated within the scope of Clinical Nutrition practice.

I give consent for my de-identified case to be discussed with other health professionals to assist with developing treatment outcomes.

I understand that payment of 50% of the total fee is required if cancelled within 24 hours of the arranged time.

If you have any questions or concerns regarding the above please discuss with Carmen further.

I confirm that I have read and accept the conditions above.

Your signature (sign by writing your first and last name) + date

EXTRA VEG NUTRITION.

PATIENT CONSENT FORM

Extra Veg Nutrition - Patient Consent Form

Declaration