Intake Form – Dinnertime Rescue

Contact Information *

Name
Phone Number
Email
Address


What is your main concern regarding feeding your family right now?


How old are your children?


PLEASE READ AND E-SIGN THE DOCUMENT BELOW

Waiver and Acknowledgement - RD

I grant permission for Jennifer House, RD to correspond with my (or my child’s) physician(s) and other necessary health care providers (i.e. Occupational Therapist, Dietitian) to obtain information relative to nutrition treatment. I acknowledge that any information provided to me by First Step Nutrition’s RD is designed to meet my personal dietary needs. It is NOT suitable for any other individuals and will not be transferred, copied or sold to another person.

In order to benefit from the treatment prescribed by Jennifer House, I realize that it is important for me to inform either my physician or Jennifer House of any changes I make in the application of my diet. It is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my treatment plan with my physician and or Jennifer House. I will not hold my physician or First Step Nutrition’s dietitian responsible for any complication that result from my failure to comply with either of the above.

I have agreed to have my Registered Dietitian keep records of our visits and to file these in a secure and appropriate place. I agree to have the Registered Dietitian contact other Health care Professionals to benefit in my care and to share my personal information. This may be accomplished by letter, phone, fax or email.

Cancellation Policy:

Twenty-four (24) hours notice is needed to cancel/reschedule your appointment. This allows our office to seek a replacement for the office time rented. If 24 hours notice is not provided, a fee of $25.00 will be charged to you.

Thank you for your cooperation and understanding.


Please sign below
By signing this form electronically, you are agreeing to the terms and conditions stated herein.