Ellen Nutrition LLC                                                        

Julie Ellen Caballero RD, MPH

Phone: 678 256 4162

Email: julieellennutrition@gmail.com

Nutrition Counseling Client Agreement

Effective 7/25/2022   Updated 11/28/2022   

General Information

A registered Dietitian does not diagnose diseases and disorders. Nutrition counseling includes education on nutrition, lifestyle, and supplements. I acknowledge I am responsible for providing accurate information regarding my medical history and symptoms, and any medications and supplements that I am taking. I acknowledge my responsibility in notifying my Medical Physician prior to making any changes in my nutrition, lifestyle (including exercise), and my decision in taking any supplements. I acknowledge full responsibility for any risks associated with making changes in my nutrition and lifestyle. I acknowledge full responsibility for any risks associated with researching brands of supplements and choosing to take certain brands of supplements. I acknowledge that Ellen Nutrition LLC, can conclude providing nutritional counseling services to me at any time, and when appropriate provide a referral. I acknowledge that Ellen Nutrition LLC, is not liable for my health outcomes and safety. I acknowledge that I am fully responsible for my health outcomes and safety. 

Appointments

Appointments must be cancelled within 24 hours of the scheduled appointment. If the appointment is not cancelled/rescheduled within 24 hours, you will be charged a $15 fee. An appointment will be cancelled if you do not arrive for in person or virtual appointments within 15 minutes of the appointment, and you will be charged a $15 fee. This fee must be paid before you reschedule another appointment.

Payment Policy for self-pay clients (non-insurance covered)

Ellen Nutrition LLC is not a preferred provider for Medicare or any insurance networks. Payments are due prior to the appointment. Payments may be cash, check, or credit card. If checks are returned, you will be charged a $15 fee. This fee must be paid before rescheduling another appointment. I agree to be financially responsible for payment of services.

Cost of Services

If there is a change in the cost of services, you will be notified ahead of time.

Nutrition counseling for 1 client:

Initial appointment 1 hour $40

1 hour follow up $40

30 minute follow up $20

During an appointment if you would like to extend the amount of time of the appointment, there will be a charge of $10 for each increment of 15 minutes.

Nutrition counseling for Group of 2 or more each person in the group will be charged:

Initial appointment 1 hour $40

1 hour follow up $40

30 minute follow up $20

During an appointment if you would like to extend the amount of time of the appointment, there will be a charge of $10 for each increment of 15 minutes.

Communication

Voicemail and email messages will be returned within 2 business days. Email may not be a secure way to send personal health information. You acknowledge if you request Ellen Nutrition LLC, to send you personal health information via email, or if you send personal health information via email to Ellen Nutrition LLC, that this may not be a secure method of communication. More secure ways to send personal health information are via in person, phone, or attaching documents with personal information on your Carepatron portal.

Consent for telehealth consultation

Consent to use the telehealth by carepatron service

Telehealth by Carepatron is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

By signing (Client or client’s parent/guardian must sign) (Parent or legal guardian must sign if patient is under 18 years of age.) this “Nutrition Counseling Client Agreement Form” I certify:

 

Printed Patient or Parent/Guardian Name: ____________________________________

 

Patient or Parent/Guardian Signature: __________________________Date: _______________