These policies apply to all packages. Please contact us at firstname.lastname@example.org for any questions, or if you have extenuating circumstances.
Consent to Treatment and Terms of Service
I understand that I am employing the services of Michelle Shepherd RD, to obtain information, resources, and guidance relating to my nutritional health. I understand that Michelle Shepherd is a Registered Dietitian with the College of Dietitians of British Columbia and will not dispense medical advice, diagnoses or treatments that are outside the scope of her practice. The information provided by her is based on the information I provide, and is designed to meet my own personal health and dietary needs and will not be transferred, copied or sold to any other third party.
I understand that it is necessary to inform Michelle Shepherd of any changes I make to my diet. I further confirm that for Michelle Shepherd to provide the relevant and appropriate recommendations, I understand and agree to:
- Provide accurate information pertaining to my personal health, to the best of my knowledge and ability;
- Advise her of any changes I make to my diet and that it is my sole responsibility to report any side effects immediately to her and my physician; and
- Advise my physician of any changes to my diet and make the necessary adjustments to my treatment plan with my physician and/or Michelle Shepherd RD.
All information obtained by Michelle Shepherd RD will be held in strict confidence, including but not limited to, verbal conversations, records of assessments and session notes. All written files are stored in a secure electronic medical record to which access is limited, or in locked filing cabinets to which only Michelle Shepherd RD has access. All information will be retained for 10 years from the last date of service or as otherwise required by the Personal Information Protection Act [SBC 2003] as may change from time to time. If you require your personal information to be provided to any third party, you will be required to first sign a specific release prior to your information being provided, such as in the case of reporting to your insurance company or other healthcare providers.
Please note that the duty of confidentiality may be limited in the following circumstances:
- If you are in imminent danger to yourself or another person, Michelle Shepherd, RD, is ethically bound to notify appropriate individuals;
- Should you bring charges or legal action against Michelle Shepherd, RD, you waive the right to confidentiality of information; or
- Any other situation where Michelle RD Shepherd has a legal duty to disclose your Information. will not be given to third parties without your consent, unless otherwise discussed (ie. reports to insurance companies or other healthcare providers).
Payments for single sessions, packages and programs are due in full at the time of booking.
Refunds are not available for services provided, or for unused portions of packages or programs with no exceptions.
- Get Me Started: 3 months from date of purchase
- Lifestyle Kickstart: 6 months from date of purchase
- Lifestyle Makeover: 12 months from date of purchase
A cancellation fee of $25 may be applied for any missed sessions, unless the appointment is cancelled 24 hours prior to the scheduled appointment time.
Contact and Communication
By signing below, I consent to Michelle Shepherd RD contacting me by email for the following reasons:
|• Video conferencing|
|• Text Message||• Website/Portal|
Michelle Shepherd will use reasonable means to protect the security and confidentiality of information sent or received through such electronic means. However, there are various risks associated with communication by electronic means, such as being inadvertently disclosed, intercepted, forwarded or stored without knowledge of the sender and complete security and confidentiality cannot be guaranteed. By consenting to communication through any of the above electronic means, I confirm I understand, am aware and voluntarily assume such risks. I hereby release, indemnify and save harmless Michelle Shepherd RD from any loss costs, expenses or damages that I may incur, whether directly or indirectly as a result of any such breach.
The College of Dietitians of British Columbia requires that you give informed consent before services are provided to you. Your signature below indicates that you have read and agree to the above and asked questions regarding anything that you do not understand.
All clients will receive a copy of this form to sign before their first session. Please connect with us for questions at email@example.com or 778-389-4802.