Disclaimer & Terms

This form is an important legal document. It explains the risks you are assuming in beginning a holistic nutrition program. It is critical that you read and understand it completely. After you have done so, clicking the “agree” box on the scheduling page will act as an assent to the terms as of the date submitted. 

Nutrition Disclaimer: The nutrition advice given by “The Functional Medicine Nutritionist” (which hereafter refers to: Christina Gentile, CHN) is solely based on the information provided by the client/individual. The nutrition information given is meant only for the client/individual completing the nutrition program. It is the sole responsibility of the client/individual to provide complete and accurate information. “The Functional Medicine Nutritionist” will not be liable for the effects of a nutrition assessment and/or advice based on any misrepresentation, misinformation, inaccuracy, or omitted information. “The Functional Medicine Nutritionist” provides nutrition counseling and is not licensed to prevent, diagnose, alleviate or treat any medical conditions, disease, physical or mental ailments or pain or infirmities. Nutrition Waiver and Covenant Not to Sue: I (client) have volunteered to participate in a nutrition program under the direction of “The Functional Medicine Nutritionist” which will include, but may not be limited to nutrition and lifestyle coaching. In consideration of “The Functional Medicine Nutritionist’s” agreement to assist me, I do here and forever release and discharge and hereby hold harmless “The Functional Medicine Nutritionist” and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in any nutrition or lifestyle coaching including any injuries resulting there from. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary. Nutrition Assumption of Risk: I recognize that specific foods may create allergic and possible fatal reactions, most specifically, products containing nuts. I have therefore specified any food allergies/sensitivities I am aware of. I am aware that specific foods may interact with certain medications. I have discussed such food reactions and the side effects of all of my medications with my doctor or pharmacist and do not hold “The Functional Medicine Nutritionist” responsible for food and medication reactions. I also understand the diet plan I receive will not take my medications into consideration. If I am on medication, I am responsible to consult with my doctor before starting a new diet plan. If I am pregnant or lactating, have high cholesterol, high blood pressure, high blood sugar, diabetes, renal disease, gastric bypass surgery, a family history of gout or any other medical condition that requires special dietary restrictions, I must receive permission from my physician before participating in the specific nutrition program designed for my use, or may be advised to seek help from another health professional.

Consent for Treatment Payment and Healthcare Options

I consent to The Functional Medicine Nutritionist’s (hereby referred to as the “Practice”) use and disclosure of my Protected Health Information for the purposes of providing treatment to me, for purposes relating to the payment of services rendered to me, and for the Practice’s general healthcare operations purposes. Healthcare operations purposes shall include, but are not limited to, quality assessment activities, credentialing, business management and other general operation activities. Additionally, the Practice may disclose my Protected Health Information to other health care professionals to provide for my proper treatment. For example, the Practice may need to discuss my medical conditions with a specialist in the instance that the Practice refers me to another health care professional to receive proper care. I understand that the Practice’s diagnosis or treatment of me may be conditioned upon my consent as evidenced by my checking agree to this document. For the purposes of this consent, “Protected Health Information” means any information, including my demographic information, created or received by the Practice, that relate to my past, present or future physical or mental health or condition; the provision of health care to me; and that either identifies me or from which there is a reasonable basis to believe the information could be used to identify me. I understand I have the right to request a restriction on the use and disclosure of my Protected Health Information for the purposes of treatment, payment or healthcare operations of the Practice, but the Practice is not required to agree to these restrictions. However, if the Practice agrees to a restriction that I request, the restriction is binding on the Practice. I understand I have a right to review the Practice’s Notice of Privacy Practices prior to the agreeing of this document. The Notice of Privacy Practices describes my rights and the Practice’s duties regarding the types of uses and disclosures of my Protected Health Information. I have the right to revoke this consent, in writing, at any time, except to the extent that the Practice has acted in reliance on this consent.

I understand the booking of a consult constitutes a legally binding assent and agree to be bound by the terms and conditions above.