(Form Copy)
I, the undersigned (“Client”) accept the terms and agreement under the administration of www.sassydietician.com/services by Ms. Divine G. Tria, RND. I fully acknowledge, read and understand the content of this matter as enumerated below.
1. Acceptance of the counselling service offered by Divine Tria, RND (@sassydietician) as a form of guidance in dietary management and other things related to this matter to obtain optimal health and nutrition condition within the clients’ control and was not being forced to accept the service or in giving personal information.
2. Acknowledge that this Nutrition Counseling does not function as a replacement of physicians order nor dispense medical advice, prescription and diagnosis. Rather it is a form of education that helps the client to have better understanding about nutrition, food and balance diet and will benefits greatly as a way of improving health and nutritional status of the client.
3. Understand thoroughly the nature of individualized recommendation which implies that all information is personally computed and assessed within the client’s profile and will not be suitable for any other individuals to be transferred, copied, or sold.
4. Aware about the therapy notes to record all the discussion and nutritional intervention and therapy plan of the Client. Records will be disclosed and will be securely keep between the two parties specifically the undersigned of this agreement. Please note for any changes or side effects during the changes should be consulted immediate to the physician as well as to the dietitian for us to do necessary adjustment needed.
Agree to hold Divine Tria, RND harmless for claims and damages during the whole consultation between the two parties involved. Not unless during the act of willful misconduct or gross negligence. Professional fees or any other service charges should be shouldered fully by the Client.
DATA PRIVACY POLICY
In compliance with RA_10173 also known as the Philippine Data Privacy Act of 2012, whose implementing Rules and Regulations took effect on September 9, 2016, you hereby agree and consent www.sassydietician.com/services managed by Divine Tria, RND, may collect, use, disclose and process your personal information that will be provided by this form.
AFFILIATION / THIRD PARTIES PLATFORM
For personal clinic visitation at Mary Johnston Hospital (Juan Nolasco St Tondo Manila), we can only accept visitors with prior appointment schedule as booked through our page (@sassydietician). As for home services, we can only cater limited areas in South Caloocan City, Manila and Tondo.
We are partnered as one of the professional beta users of Nutricoach – an mobile-friendly app as your food tracker. Both are available on Google Play & Apple Store. During the consultation, We will be sending updates, meal plans, and other forms through this application. You can sign up, download, and use the app for FREE.
NUTRITION CONSULTANCY SERVICE TYPE
MEDICAL NUTRITION THERAPY – Choose this service if your goal is to address certain health condition and was advise by your physician to consult a Licensed Dietitian for your food plan. It is a Personalized Diet Plan (with Doctor’s Referral) that are based from your needs.
- Requirement : Recent Laboratory Examination Result (at least within 6 months), Doctor’s Referral and Previous Diet Order (optional).
- Inclusion : Nutrition Counseling, Relevant Dietary Management Guide, One Day Sample Menu and Grocery List
- Additional Charges : *prices varies
- Conversion of Sample Menu or Menu Planning (a) One Week (b) Two Weeks (c) One Month
- Inclusion of Recipes with caloric counts
- Follow up Professional Fees
WEIGHT MANAGEMENT PROGRAM – Dietary Instructions given to individual whose main goal is either to loss or gain weight with or without medical advice. But for those with diagnosed health concern, make sure to seek medical advice first before applying to this program. This program will have a minimum of ONE MONTH subscription duration.
- Inclusion : Nutrition Counseling, Relevant Dietary Management Guide, One Month Cycle Menu, Exercise & Physical Activity Guide, and Grocery List
- Additional Charges : *prices varies
- Program Subscription Length (a) 3 Month (b) 6 Months (c) 12 Months
- Inclusion of Recipes with caloric counts
- Follow up Professional Fees
BLENDERIZED DIET or TUBE FED PATIENTS – A specialized diet given to patient that need Nutrition Support through Enteral Feeding. These patients are usually have problem in eating food orally and dependent to tube inserted to Nose or Directly from your Gastrointestinal Tract as their way of eating.
- Inclusion : Nutrition Counseling, Relevant Dietary Management Guide with video clip copy
- Additional Charges : *prices varies
- Home Service Charge
- Conventional Blenderized Feeding Preparation
- Follow up Professional Fees
OTHERS / MISCELLENEOUS – (1) General Medical Nutrition Therapy Guide (Disease-Specific), (2) Recipe Development (per piece or bundle), (3) One Week Menu Plan with Calorie Counting (4) One Month Cycle Menu with Grocery List.
Fill up this Initial Nutrition Assessment Form here. This will help the Dietitian to assess your current nutritional status and to provide the best nutrition intervention you really need. By the end of the form, you will be able to book an appointment to discuss your result.
Revised on August 8, 2022*