PRE-BOOKING WAIVER

First name

Last name

Date of Birth

Phone

I consent to receiving support from Zoe Brown Nutrition with regard to my nutritional health.

I consent to online and telephone consultations – I understand that I will have to provide my own measurements for these consultations and that if the connection is not adequate that the session may have to be terminated. I also understand that no children should be left unattended on the call whilst the consultation is taking place otherwise the session will be terminated. I also understand that the nutritionist will ask my location for each consultation for safety purposes.

I consent to face to face consultations.

I give consent for Zoe Brown Nutrition to contact me regarding my nutrition support including sending relevant resources:

by post using the address above.

by email using the address above.

by telephone using the number above.

The support is not a substitute for medical advice. By consenting to this service, the client agrees to follow the guidance of their medical team including, but not limited to, their GP.

I give consent for Zoe Brown Nutrition to contact my GP where deemed appropriate as part of nutrition support by letter. I understand that I will always be told a letter is going to be sent prior to it being sent and that I will receive a copy of this letter.

Name of GP

GP Address

Use of Personal Data

Notes will be taken during the session. A copy of your notes will be sent to you after the consultation. You are responsible for letting Zoe Brown Nutrition know within 48 hours of the appointment if there are any inaccuracies in the
notes so that they can be rectified. Your case may be discussed with another nutritionist registered with the
Association for Nutrition should support or supervision be required but no identifiable details will be given. Only in cases of safeguarding, or other situations under UK law, will confidential information be shared with third
parties. Your data will be held by Zoe Brown Nutrition in line with General Data Protection Regulations which are available on request. To change your preferences at any point email zoebrownnutrition@gmail.com

I agree not to record any sessions or, in the case of telecommunication, share my screen during sessions without prior consent from Zoe Brown Nutrition.

Limitations of the service

In certain circumstances, once the service has commenced, information may be revealed which means that the Registered Nutritionist is not qualified to support the client further. If this happens the client will be informed within 5
days of the consultation and will be given details of other professionals who may be able to help. Every step will be taken to ensure this comes to light before sessions commence but if sessions have already commenced, the client is required to
pay for the sessions already delivered. The Registered Nutritionist accepts no liability for the services provided by
other professionals.

In order to help the process of ensuring Zoe Brown Nutrition is the right person to support you, please provide the following information:

Health statistics (please fill in what you know, don’t worry if you are not sure)

Weight and date you were weighed (if you do not want to provide this information please leave blank)

(Ensure scales are on a hard flat surface and weigh yourself with minimal clothing – note the weight in kilograms)

Height and date you were measured (Place a book on the top of the head making a mark on wall (or paper on the wall) where the underneath of the book touches the paper. At all times ensure you are standing still, with the heels against the wall and knees straight. The inside of your ear should be level with your eyes. Measure to the floor)

Medical history

Details and doses of any medication you are on, including supplements and herbal remedies

Do you have any long term conditions or other conditions you think I should be aware of, including allergies? Include information of any hospital referrals.

Payments

Payment for the service will be made when booking the appointment. Failure to do so may result in the appointment being given to someone else. Payment ¥10,000 can be sent by bank transfer.

Cancellations

If the client cancels a consultation within 24 hours of the appointment, or fails to attend, the client will have to pay the full amount for the session. If more than 24 hours’ notice is given by the client, or the Registered Nutritionist cancels a consultation, a refund will be issued or the appointment time changed without additional charges.

Complaints

I, Zoe Brown Nutrition always use reasonable efforts to ensure that my provision of the Services is trouble-free. If, however, there is a problem with the Services, I request that You inform me as soon as is reasonably possible.

Governing Law and Jurisdiction

The Agreement, and the relationship between You and me, Zoe Brown Nutrition, (whether contractual or otherwise) shall be governed by, and construed in accordance with the law of England & Wales.

Any dispute, controversy, proceedings or claim between You and me, Zoe Brown Nutrition, relating to the Agreement, or the relationship between You and Us (whether contractual or otherwise) shall be
subject to the jurisdiction of the courts of England & Wales.

Confirmation

I agree to the above terms and conditions and confirm that, to the best of my
knowledge, the information given in this form is accurate and complete.

Signature (client)

Select a date

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