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Holistic Nutrition Services Consent to Consult & Legal Release of Liability Form

I understand that Holistic Nutrition Services LLC is not a licensed medical provider, and therefore does not give medical advice. Any medical advice should be discussed with my medical provider. Any suggestions or topics discussed during sessions will be up to me to make final decisions using my expertise of my unique needs. Resources provided are intended to bring knowledge and awareness of topics related to holistic health across the lifespan including preconception, pregnancy, and childhood, and do not constitute a medical treatment plan.


I understand that video conferencing may be used as the platform to consult. Neither party shall record and/or save audio, video, or screenshot images of the consultations for either private or public/social media uses. Neither party will share audio, video, nor screenshot images of consultations for any reason. Failure to comply is subject to result in legal action. These guidelines are in place to protect my and my child’s Protected Health Information (PHI) in accordance with the Health Insurance and Portability Act (HIPAA). The VSee video conferencing software is HIPAA compliant, and Holistic Nutrition Services LLC holds a Business Associate Agreement with VSee to maintain HIPAA compliance. Learn HIPAA rights at www.hhs.gov/hipaa


I understand that Holistic Nutrition Services LLC will not be held liable for technology issues, such as poor internet connection, resulting in loss of consultation time. To maximize my session, I am encouraged to set up equipment at least 5 minutes prior to the session start time. Holistic Nutrition Services will do their best to work through any technological

issues that arise and may offer a rescheduled time at her discretion if technological issues cannot be solved during the scheduled time.


I understand my session payment of $107 (for a single session) or $90 (for four (4) consecutive weekly sessions booked at once) covers Holistic Nutrition Services review of my documents and consultation for 60 minutes due prior to the start of session. A $5 Late Payment fee will be incurred for each day late. Additional services or request for letters will result in separate charges that will be agreed upon prior to receiving the support.

It is solely up to Holistic Nutrition Services’ discretion to determine if a rescheduled time can replace a forfeited refund depending on the emergency circumstances.


If I need to cancel, I will email partneringwithparentsllc@gmail.com with

the subject heading: ‘Canceling Session’ with the session’s date and time. For example, ‘Cancelling Jan 1 at 11:30am.’ Refunds may take up to 10 business days to process.



I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms

and conditions stated above. This written agreement supersedes any prior oral agreements and can only be altered by

the written consent of both parties.

Who will be receiving Holistic Nutrition Services?
Adult
Child

If you selected 'Child' above, please fill out the following section:

Select which Consultation Plan you'd like to purchase:
Single Session ($107/each)
Weekly Consecutive Plan ($90/each)
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Form Submission Date
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