Nutrition Information Form

NUTRITION INFORMATION FORM & SERVICE AGREEMENT

Parties and Identifying Information

Service Provider Name:

Client Name:

Recitals

WHEREAS, Service Provider is a qualified nutrition professional authorized to provide dietary assessment, individualized nutrition planning, and related advisory services; and

WHEREAS, Client desires to receive nutrition services from Service Provider and has provided truthful and accurate background and health information to permit the provision of appropriate nutritional guidance; and

NOW, THEREFORE, in consideration of the mutual covenants set forth herein, the parties agree to the terms below governing the provision of nutrition services and the collection and use of the Client's nutrition information.

Nutrition and Medical History

Current Dietary Habits

Goals and Preferences

Scope of Work

The Service Provider will perform the following services for the Client, subject to the terms of this Agreement. Services may include assessment, individualized meal planning, nutrition education, progress monitoring, and written recommendations.

Payment Terms

Client shall pay Service Provider for services in accordance with the schedule below.

Late payments shall incur a late fee of on the unpaid balance, calculated monthly. Client is responsible for all collection costs and legal fees reasonably incurred to recover unpaid amounts.

Term and Termination

This Agreement shall commence on and shall terminate on unless earlier terminated as provided below.

Either party may terminate this Agreement for convenience upon days written notice. Termination for material breach is immediate if the breaching party fails to cure within ten (10) days after receipt of written notice of breach. Termination does not relieve Client of the obligation to pay fees for services performed through the termination date.

Confidentiality

Service Provider shall maintain the confidentiality of Client's health and nutrition information and shall not disclose such information except: (a) as necessary to provide services under this Agreement; (b) with Client's prior written consent; or (c) as required by applicable law. Service Provider will implement reasonable administrative, technical and physical safeguards to protect Client information. Client authorizes Service Provider to share pertinent information with other health care providers when necessary for coordinated care.

Acknowledgements and Certifications

Client certifies that the information provided in this form is true and complete to the best of Client's knowledge. Client understands nutrition advice is advisory and not a substitute for medical diagnosis or treatment. Client agrees to notify Service Provider promptly of any changes to medical status, medications, or adverse reactions to dietary recommendations.

By signing below, Client authorizes Service Provider to create and retain nutrition records, and acknowledges receipt of privacy and service provision notices provided at or before the time of service.

Governing Law; Entire Agreement

This Agreement shall be governed by and construed in accordance with the laws of the state specified by the parties. Any dispute arising under this Agreement will be subject to the exclusive jurisdiction of the state and federal courts located in the governing jurisdiction. This Agreement, together with any written attachments and scopes of work signed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations, or agreements, whether written or oral.

Consent for Limited Use of Information

Client consents to the use of de-identified aggregate data for quality improvement and research purposes provided such data does not include personally identifiable information. Client may revoke this consent in writing at any time, except where action has already been taken in reliance on prior consent.

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