Forms

Informed Consent Form

  • The purpose of this form is to not hold Balance and Rejuvenate Nutrition Services LLC harmless for claims or damages in connection between the client and Erin Swietlik RD. Erin will keep all information private by following the standards under HIPPA (Health Insurance Portability and Accountability Act). It is the clients understanding that Erin is licensed to provide medical nutrition therapy and is not a substitute for the care under a medical doctor.

Womens Health History Form

  • It provides Erin information about your dietary, sleeping, exercise, and general lifestyle habits and as well as your personal health goals. The information will direct Erin in what needs to be addressed during the initial nutrition session.

Food Recall Form

  • This brings awareness to your eating patterns. It is important to be honest with what you write down, do not feel guilty! This is only used as a tool to help establish the right eating patterns for long-term success.