This policy provides information on privacy pertaining to clients of Branco Nutrition.
INFORMED CONSENT AND TERMS OF SERVICE
Collection of Personal Information
I accept that it will be necessary for agents of Branco Nutrition (a division of Branco Consulting) to collect personal, health and lifestyle information such as contact information, dietary habits and medical history. I understand that only information relevant to the provision of services for my nutritional management will be collected.
Use of Personal Information
I am hiring the counselling/consulting services of Branco Nutrition. I acknowledge Branco Nutrition will provide information and guidance about health factors within my own control: my diet, nutrition and lifestyle in order to nourish and support my individual health and wellness. It is NOT suitable for any other individual and will not be transferred, copied or sold to another person.
I understand that Branco Nutrition employs Registered Dietitians and Nutrition Coaches (not medical physicians) and does not dispense medical advice, nor will they diagnose or treat any medical condition. I understand nutrition counselling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider, but will provide nutritional support and nutrition education for an already diagnosed condition. Rather, they provide education to enhance my knowledge of health as it relates to foods, dietary supplements, and behaviours associated with eating. While nutritional support can be an important compliment to my medical care, I understand these services are not a substitute for medical care.
In order to benefit from the nutritional recommendations by Branco Nutrition, I acknowledge that it is important for me to inform my physician of any diet changes. It is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my nutrition plan with my physician and/ or Branco Nutrition. I will not hold Branco Nutrition responsible for any complications that result from my failure to comply with the above.
Disclosure of Personal Information
I acknowledge that any information obtained will be held in strict confidence. Branco Nutrition operates with a team approach, thus information obtained may be shared with other Registered Dietitians or Nutrition Coaches of Branco Nutrition. Branco Nutrition will not share personal information unless authorized or required by law or court order, or with the individuals’ consent.
I further acknowledge that some or all communication between me and Branco Nutrition may be via electronic systems such as email or teleconferencing. I understand that the benefits and risks from communicating online/ over the phone, including, but not limited to, the possibility, despite reasonable efforts on the part of Branco Nutrition, that the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
☐ I agree to have a Registered Dietitian contact other Health Care Professionals if applicable to benefit in my care and to share my personal information. This may be accomplished by letter, phone, fax, or email (per Personal Information Protection and Electronic Documents Act (PIPEDA)).
Furthermore, I give permission for this information to be shared with the following individuals upon request:
Retention of Personal Information
I acknowledge that my personal information including all communications and chart notes will be kept as a record of our work together. This information will be filed in a secure and appropriate place and will be retained as long as it is required to fulfil the identified purposes above and for ten years following the last date of service (or ten years following my eighteenth birthday, whichever is longer.)
Access to Personal Information
I understand that I may review the information in my file for accuracy and currency. If I disagree with the information, I accept that a correction may be made and my disagreement will be noted.
I understand that I may review this Policy of Branco Nutrition so I can fully understand how it applies to me. I know that at any time I may ask questions about this Policy, and have them answered to my satisfaction. This is available to me at any time.
I agree to hold Branco Nutrition and its staff harmless for claims or damages in connection with our work together. This is a contract between Branco Nutrition and myself and I understand that it is also a release of potential liability.
I acknowledge that I have been informed of the above and I voluntarily consent to collection of personal information and the subsequent use and disclosure of this information.