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COUNSELING P ROGRAM

NUTRITIONAL

INFORMED C ONSENT A GREEMENT A ND R ELEASE O F L IABILITY

I _ _______________________ g ive c onsent t o T he U niversity o f T exas a t D allas E mployee

Wellness C enter t o p rovide N utrition C ounseling t o m yself. T he c onsult w ill p rovide i nformation

and g uidance a bout h ealth f actors w ithin m y o wn c ontrol: m y d iet, n utrition a nd l ifestyle.

I u nderstand t hat D eborah H amlin, R D, L D, i s a r egistered d ietitian – n ot a m edical p hysician –

and d oes n ot d ispense m edical a dvice, n or w ill s he d iagnose o r t reat a ny m edical c ondition, b ut

will p rovide n utritional s upport a nd n utrition e ducation f or a n a lready d iagnosed c ondition. S he

provides e ducation t o e nhance m y k nowledge o f h ealth t hrough t he u se o f w hole f oods, d ietary

supplements a nd e motional a wareness. W hile n utritional a nd b otanical s upport c an b e a n

important c ompliment t o m y m edical c are, I u nderstand t hese s ervices a re n ot a s ubstitute f or

medical c are, a nd t hat I w ill n ot s eek m edical c are o r a dvice f rom D eborah H amlin R D, L D.

Methods o f n utritional e valuation o r t esting m ade a vailable t o m e a re n ot i ntended t o d iagnose

disease. R ather, t hese a ssessment t ests a re i ntended a s a g uide t o d eveloping a n a ppropriate

health-‐supportive p rogram f or m e, a nd t o m onitor m y p rogress i n a chieving m y g oals. M edical

records a nd p ersonal i nformation a nd h istory d ivulged i n s ession t o D eborah H amlin R D, L D w ill

be o n a v oluntary b asis a nd w ill b e k ept c onfidential t o t he e xtent p ermitted b y l aw, u nless I

consent t o s haring m y m edical i nformation.

In c onsideration f or m y p articipation i n t he N utrition C ounseling p rogram, I h ereby a ccept a ll

risks t o m y h ealth t hat m ay r esult f rom s uch p articipation. I h ereby r elease U TD, i ts g overning

board ( The U niversity o f T exas S ystem B oard o f R egents), o fficers, e mployees a nd

representatives i n t heir i ndividual a nd o fficial c apacities, f rom a ny l iability t o m e, m y

personal r epresentatives, e state, h eirs, n ext o f k in, a nd a ssigns f or a ny a nd a ll c laims a nd

causes o f a ction f or a ny a nd a ll i llness o r i njury t o m y p erson, i ncluding m y d eath, t hat m ay

result f rom o r o ccur d uring m y p articipation i n t he N utritional C ounseling p rogram, W HETHER

CAUSED B Y A NY T YPE O F N EGLIGENCE O F U TD, I TS G OVERNING B OARD, O FFICERS,

EMPLOYEES, O R R EPRESENTATIVES, O R O THERWISE.

I f urther a gree t o i ndemnify a nd h old h armless U TD a nd i ts g overning b oard ( The U niversity

of T exas S ystem B oard o f R egents), o fficers, e mployees, a nd r epresentatives, i n t heir

individual a nd o fficial c apacities, f rom l iability f or t he i njury o r d eath o f a ny p erson(s) t hat

Informed Consent Agreement And Release Of Liability