HOLISTIC NUTRITION CONSULTATION
ALL INFORMATION IS CONFIDENTIAL
Do you have any complaints about any of the following?
Do you eat at regular times each day?
Present marital status:
Do you use convenience foods daily?

Informed Consent Agreement​

I give consent to D’Auria Esthetics and Wellness to provide Nutrition Counseling to myself or the client for which I am legally responsible. The consult will provide information regarding my health, lifestyle and diet.
 

I understand that Alexandria D’Auria is a certified Holistic Nutritionist and certified Health and Wellness Coach and not a medical physician. Thus, she will not diagnose medical conditions, but will provide nutritional support and nutrition education. I understand these services are not a substitute for medical care. Methods of nutrition counseling made available to me are not intended to diagnose disease.
 

I have read this consent form and terms contained herein carefully. I understand the terms of this form fully and voluntarily agree to be bound by them.

Thanks for submitting!