Before beginning Functional Nutrition Therapy with your Functional Nutrition Therapist
(“FNTP”), please read the following information carefully and then sign and date at the bottom of this page.

The fundamental goal of Nutritional Therapy is to encourage people to become knowledgeable about—and responsible for—their own health. An FNTP helps individuals reach their optimal level of overall health by supporting and bringing balance to the five foundations listed below. All five are built upon a single, solid base: a properly prepared, nutrient-dense diet.
• Digestion
• Blood Sugar Regulation
• Fatty Acid Balance
• Mineral Balance
• Hydration
By supporting each of these foundations and helping clients adopt a more nutrient-dense diet, the body’s chemistry can be brought back into natural balance, setting the stage for optimal health.
Nutritional Therapy is not designed, however, to treat any specific disease or medical condition. A Functional Nutrition Therapist is trained to evaluate your nutritional needs and make recommendations of dietary change and nutritional supplements, not medical diagnoses or prescriptions. No comment or recommendation from your FNTP should be construed as a medical
diagnosis or prescription.
Reaching optimal health requires sincere commitment, possible lifestyle changes, and a positive attitude. If you are not willing to change how you eat and live, Nutritional Therapy is not the right approach for you. Since every human being is unique on a biochemical level, we cannot guarantee
any specific result from our programs.

If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. An FNTP is not a substitute for your family physician or other appropriate healthcare provider. A Functional Nutrition Therapy Practitioner is not trained nor licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases or prescribe medications.
If you are under the care of another healthcare provider, it is important that you contact your other healthcare providers and alert them to your use of nutritional supplements. Nutritional Therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your
nutritional program.
If you are using medications of any kind, you are required to alert the FNTP to such use, as well as to discuss any potential interactions between medications and nutritional products with your pharmacist. If you have any physical or emotional reaction to Nutritional Therapy, discontinue their
use immediately, and contact your FNTP to ascertain if the reaction is adverse or an indication of the natural course of the body’s adjustment to the therapy.

Every client is a biochemical individual, and it is not possible to determine in advance how your body will react to the nutrients or supplements you need. It is sometimes necessary to adjust your program as we proceed until your body can begin to properly accept targeted nutrients geared to correct imbalances or deficiencies. It is your responsibility to do your part by:
• Following the nutrition guidelines provided by your FNTP.
• Eating a properly prepared, nutrient-dense diet.
• Avoiding harmful foods, substances, and behaviours.
• Moving your body daily.
• Getting plenty of sleep, rest, and relaxation.
• Staying in contact with the NTP so they can stay abreast of your progress and provide the best course of action going forward.
If your other healthcare providers have any questions regarding Nutritional Therapy, they are free to contact your FNTP.

During the course of Nutritional Therapy, your FNTP will ask that you provide relevant personal details and information relating to your background, health, lifestyle, etc. (hereafter referred to as “Information”), including but not limited to:
• Your full name, physical address, email address, phone number, date of birth, etc.
• Your health history, including injuries, surgeries, prescriptions, etc.
This Information will be gathered from you via in-person interviews, questionnaires, evaluations, intake documents, phone, email, mail, video conferences, etc., and used to:

Help assess your nutritional needs.
• Make recommendations for dietary changes and nutritional supplements to support your specific nutritional needs and goals.
• Comply with all legal and NTA training obligations.
To ensure the maximum benefit of Nutritional Therapy, it is important that your Information is accurate and up-to-date. If you notice any changes to your health, begin taking new prescriptions, etc., please notify your FNTP as soon as possible. It is also your right as a client to access, update, or delete your records at any time. To do so, simply notify your FNTP in writing. Your FNTP will retain your Information for the length of time you are a client, after which they will take reasonable steps to dispose of your Information in a secure fashion.
Though FNTPs are not HIPAA regulated entities, the FNTA is committed to protecting client privacy and requires FNTPs to uphold the privacy best practices and the policies laid out in the U.S. Standards for Privacy of Individually Identifiable Health Information. Your FNTP will take all reasonable steps to protect your Information from unauthorized access, use, or disclosure by using strong passwords, up-to-date software on all devices, and locking file cabinets for physical documents. However, even the best security practices cannot guarantee that all stored data will be completely free from third-party interception or corruption.
In accordance with Standards for Privacy of Individually Identifiable Health Information, your consent is required for your FNTP to collect, use, and disclose your personal Information. By signing below, you acknowledge consent for your FNTP to collect your Information.

By submitting form below, I confirm that I have read and fully understand the above disclaimer, am in
complete agreement thereto, and do freely and without duress sign and consent to all terms contained herein:

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