I hereby enter into the following agreement with Izette Faul Dietitians, PR0255904.

1. Consent for Nutritional counseling

1.1 I hereby request and give consent to Izette Faul Dietitians to provide Nutrition Counseling to myself, or the client I am legally responsible for.

1.2 I understand that the counselling will provide information and guidance about my diet, nutrition, and lifestyle.

1.3 I understand that Izette Faul Dietitians is a Registered Dietitian and does not dispense medical advice, but will treat a diagnosed medical condition through medical nutrition therapy.

1.4 Methods of nutrition evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessments are intended as a guide to enhance my nutritional health.

1.5 Izette Faul Dietitians will provide nutritional support and education that relates to existing medical conditions, prevention of chronic diseases, improved athletic performance and or for general healthy eating habits.

1.6 I understand that all available information and all vital information regarding my medical conditions, diet, nutrition, and lifestyle need to be disclosed to Izette Faul Dietitians and I acknowledge and accept the risks of non-disclosure.

2. Confidentiality

2.1 Medical records and personal information and history divulged in the sessions to Izette Faul Dietitians will be kept confidential unless I consent to sharing my medical information.

3. Consent to Telehealth / Web based Counselling

3.1 When I would like nutritional advice provided through telehealth or web-supported platforms (including but not limited to Zoom, Microsoft teams, Skype or Telephonic) I understand that these platforms will be used to provide healthcare services to me, and that the usual consent processes are followed.

3.2 I understand that the consultation will be done via video/internet conferencing technology, and I agree to this.

3.3 Practicalities:

3.3.1 The telehealth or web-supported consultation is done through a two-way video whereby Izette Faul Dietitians can see my image on the screen and hear my voice.

3.3.2 Any paperwork exchanged will be provided through electronic means.

3.3.3 I understand that telehealth may have limitations, such as data-and internet failures (e.g., dropped calls or bad reception).

3.4 I understand and give consent that the telehealth consultation being recorded.

4. Reimbursement

4.1 I understand that I will be billed for a consultation at the rates indicated by Izette Faul Dietitians. This will be cash payment or EFT in advance.

4.2 I will be liable for the recovery cost of outstanding accounts, should I not honor my liability. I will inform the practice of any changes of my contact details, medical aid, or address. 

4.3 I accept that my account will be processed by a third party. 

5. Cancellation 

5.1 Appointments must be cancelled before 8:00 on the day of the appointment and if not I will be responsible for the fees involved. 

The patient agrees and records that he/she shall not hold the practitioner liable for any loss, harm, or damage which the patient may suffer pursuant to treatment by the practitioner in cases where there was a failure by the patient to disclose medical information. Furthermore, I indemnify the practitioner against claims of any nature made by third parties which arise out of the treatment of the patient by the practitioner.