Waiver & Consent Form

This is a required step for booking your Nutrition Appointment with Modest Nutrition. In order to ensure the safety or your medical/health information and your nutrition-medical care, we require that you read and agree to the following conditions:

 

  • I hereby grant permission to my Registered Dietitian (at Modest Nutrition), to contact my physician(s) and health care providers, when needed, to obtain information relevant to my nutrition treatment and counseling. This may be accomplished by letter, phone, fax, or email; as per the Personal Information Protection and Electronics Documents Act (PIPEDA).

 

  • I agree to have my Registered Dietitian keep records of our visits and to file these in a secure and appropriate place, which will be held in strict confidence.

 

  • I consent to exchange of information of my dietetic treatment to be send electronically (if needed) to the email that I provided above, which is a secure and safe address that only I have access to. I acknowledge that privacy cannot be guaranteed in electronic communication and it is both mine and my dietitian’s responsibility to maintain confidentiality.

 

  • I acknowledge the information provided to me by my Registered Dietitian 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, I will inform either my physician or dietitian of any changes I make to 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 registered dietitian. I will not hold my physician or dietitian responsible for any complications that result from my failure to comply with either of the above.

 


Insurance Reimbursement

The services of a Registered Dietitian are not covered by Ontario Health Insurance Plan (OHIP). Some private insurance carriers do cover some of the cost. Check you private insurance carrier for details. We do not do directly billing, we can provide you with a receipt with details of your visit; however it is your responsibility for submitting costs to your insurance company.


Tax Reimbursement

Registered Dietitians in Ontario are classified as “Authorized Medical Practitioner.” Retain your receipt and you may be able to claim the fees as non-refundable tax credit for medical expense, from the government. Visit Canada Revenue Agency website for details.


Refund Policy:

We offer 100% refund if you cancel more than 24 hours
before your initial appointment for the service/package.

Fees are due at or before each visit and with each service, depending on the package/payment plan chosen. All service fees are non-refundable after service is rendered (regardless of the time spent – all service timings are estimated +/- 20 minutes). If you cancel your package in the middle, you may qualify for a refund of up to 50%. All banked visits must be used within a year of purchase, unless previously arranged.

We do NOT issue a refund under these conditions:

♦  After you have completed your appointment and the services are rendered

 ♦  If you cancel or reschedule within less than 24-hours of your appointment

It is your responsibility to book and keep your appointments.

All no shows will be regarded as a completed visit!


I declare that the information provided is true and accurate at the time of signing and that I have understood and agreed to the above.

I Agree & Consent*

*Required