Collection of Information

Before your session we will send you by email an 8 page intake form, so you can give the nutritionist more detailed information about your medical history, complicating symptoms, medication, and supplements. We take your health history and wellness goals seriously.

Privacy and Confidentiality

We guarantee we treat your information with privacy. We will only utilize your medical and health information in the context of your office appointment, to write reports for our records, and only with your permission contact other health professionals for discussion or exchange of information (including reports to your doctor). You must sign a waiver with your signature for this to occur in the course of treatment. Your confidential appointment will not be discussed with any other health professional without your consent and signed waiver.

Your appointment will be kept between you and the practitioner, unless you request otherwise. This is signed to before the first appointment. For waiver signed prior to first appointment, please see below for example.

Waiver Signed by Client (With the Understanding That We Also Carry Insurance)

I understand that a nutrition session with nutritionist Emily Isaacson is designed for nutrition education, analysis, and assessment. It does NOT provide specific information about diseases nor diagnose any disease. Instead, it provides information about food, vitamins, minerals, supplements, herbs, and nutrition.
 
I waive the right to pursue any legal action in response to the service rendered or supplements obtained and taken through the Wild Lily Holistic Health Clinic. I waive any legal right in objection to advice not rendered, the result of any nutrition consultation, in following instructions, or in response to information given to me by nutritionist Emily Isaacson, either in clinical session, by coffee shop consult, by email, by phone, or by home visit. 
 
I agree to be responsible for the results and outcome of my own healing journey. I am able to get a second opinion or consult with a physician if my condition worsens or I am unsure of the result, such as a supplement conflicting with any prescribed medication.
 
I agree to phone the nutritionist immediately in case of a reaction to my supplements or a crisis so I can be referred to the appropriate care. (We provide number.)

All appointments with the practitioner are confidential, and the information she gives you is not to be applied to another person or disclosed for your own safety.
 
Signed: ___________________________