Informed Consent

NUTRITION SERVICES TO BE PROVIDED

Janell Kaplan is a Non-Dietician Nutrition Professional and Licensed Massage Therapist in the commonwealth of Kentucky with a Bachelor of Science in Health Sciences and Psychology, Master of Science in Human Nutrition in progress, Board Certification in Functional Medicine in progress, Board Certification in Therapeutic Massage and Bodywork, and Certifications in CranioSacral Therapy, SomatoEmotional Release, Corrective Exercise, and other modalities, based in the commonwealth of Virginia and the owner of Indomitable Spirit, LLC doing business as Nova Functional Nutrition (“NFN”).

Janell’s goal is to help you achieve your highest level of health and well-being, consistent with your goals. Nutrition is an important adjunct to the care provided by your medical doctor and/or mental health professional, but it is not a substitute for medical or psychological care. Services offered as part of a consultation may include diet, nutrition, and lifestyle coaching, counseling, and education, including but not limited to recommendations for nutritionally-relevant laboratory assessment, food plans, meal plans, and recipes, functional foods, nutritional supplements, including but not limited to vitamins, minerals, amino acids, fatty acids, herbs, and botanicals, exercise and movement, sleep and relaxation, and a range of other lifestyle modifications that can influence health. As part of a consultation, Janell may perform a comprehensive diet, nutrition, and lifestyle assessment; plan and implement a diet, nutrition, and lifestyle plan; and monitor and assess your progress. Individualized nutrition counseling is subject to the dietetics/nutrition laws in your home state. As such, Janell’s recommendations may be more generalized and less individualized depending on the laws in your home state.

Although Janell has extensive diet, nutrition, and lifestyle training and experience, she cannot and does not diagnose or prescribe for any medical or psychological conditions. Janell is not a Medical Doctor (MD), Doctor of Osteopathy (DO), Naturopathic Doctor (ND), Registered Dietician (RD), or Certified Nutritionist (CN). Recommendations are made available to you for informational purposes only and are not intended to diagnose, prevent, treat, or cure any medical or psychological conditions, nor should they be considered as such.

NOTICE OF PRIVACY POLICY

All client information is handled under the Health Insurance Portability and Accountability Act (HIPAA). The privacy of your protected health information, as described in HIPAA, is important to NFN. As a Client of NFN a record of your care and services will be created. This record is necessary to provide you with quality care and to comply with certain legal requirements. NFN will not use or disclose your health information for any purpose without your explicit written authorization. Any explicit written authorization you provide may be revoked at any time by writing to NFN at the office address. NFN may use health information about you to provide you with nutrition or other services and may disclose health information about you to doctors, nurses, and other healthcare providers to assist them in treating you. NFN may use and disclose your health information for payment purposes. A bill or receipt may be sent to you or a third-party payer. The information on or accompanying the bill or receipt may include your health information.

COMMUNICATION

The confidentiality and security of email communication to and from NFN between consultations cannot be guaranteed. Information stored on our computers is encrypted, as is the information stored on our cloud-based accounts: G Suite, Acuity Scheduling, Healthie, and Living Matrix. Most email service providers (i.e., Gmail, Hotmail, Yahoo, etc.) do not use encrypted email. When you send an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the internet. In addition, once an email is received by you, someone may be able to access your email account, and read it. Email is a convenient and popular way to communicate for a lot of people, so in accordance with the latest modification to the HIPAA act, we are making you aware of the risks of unencrypted email.

I agree that NFN shall not be liable for any breach of confidentiality that may result from my use of unencrypted email. I understand that NFN may email me resources as part of my diet, nutrition, and lifestyle plan. I understand that email communication may be made part of my permanent health record and would be accessible to anyone given access to those records. I understand that I may revoke my consent for email communication at any time by writing to NFN at the office address. I hereby consent to email communication from NFN.

CLIENT RIGHTS AND RESPONSIBILITIES

You are responsible for making Janell aware of all medical conditions, medical therapies, if you are pregnant, thinking of becoming pregnant, or breastfeeding, or if there are any changes to your health or medical therapies as you continue to work with Janell. You have the right to respectful, courteous care and can refuse to follow any or all recommendations provided as result of this consultation. You have the right to choose another nutrition professional for any reason and request that health information be disclosed to another nutrition professional or healthcare provider. You are responsible for making your healthcare providers aware of your diet and nutritional supplements currently in use. If you are experiencing signs or symptoms, or have reason to believe a medical or psychological condition exists, you are responsible for contacting a medical doctor or mental health professional. If you have reason to believe you may require emergency medical care, you are responsible for calling 911 or going to the nearest emergency room.

SUPPLEMENT SAFETY

Time-honored traditional and modern medical literature indicate that commonly used nutritional supplements have a good safety record. And, confirmed cases of supplement-drug interactions are rare. However, interactions and adverse events can occur with use of any supplement, just as they can occur with the use of any food or physician prescribed drug. As such, it is imperative that you disclose to Janell: (A) all medical conditions past and present, including but not limited to liver or kidney disease; (B) all medical and natural therapies currently in use; (C) any known or suspected allergies; and (D) if you are pregnant, thinking of becoming pregnant, or are breastfeeding. Nutritional supplements should be taken at the recommended dosage. And, you are expected to inform your physician and other healthcare professionals of nutritional supplements currently in use. Any evidence of a supplement-drug interaction should be reported immediately to Janell and the prescribing physician. Nutritional supplements should be stopped seven (7) days before and after a surgical procedure and/or the introduction of a new medical therapy, unless explicitly instructed otherwise by Janell and your prescribing physicians.

INFORMED CONSENT

I understand and agree that I am solely responsible for the decision to consult with NFN. I have reviewed this document, including the services to be provided, notice of privacy policy, communication, client rights and responsibilities, supplement safety, and informed consent. I understand that Janell is not a medical doctor and that she cannot and does not diagnose or prescribe for any medical or psychological condition. If I have not done so already, I agree to consult a medical doctor for any serious or life-threatening health condition or dis-ease, either for myself or someone under my guardianship. I understand that no recommendations are being made to discontinue any medical therapy being provided by a medical doctor or other qualified healthcare provider. I represent that I am seeking nutrition services to further my own health and well-being, or that of someone under my guardianship, and that I do not represent a third-party. I have had the opportunity to ask Janell questions regarding the nutrition services and this consent form, and have received satisfactory explanations. I understand that I may withdraw this consent in writing and that I am free to discontinue service(s) at any time. I hereby consent to the nutrition services to be provided by NFN.

Last Updated August 27, 2018