Straight Nutrition ™

This is a confidential client symptom survey. Please check each condition which is true for you. If the condition does not apply to you or you do not understand a term or if you are not sure if a condition applies to you, then do not check the box. Use common sense. For example, Insomnia once in the last month probably isn't that important and would not be marked. However, Insomnia occurring 1-2 times per week is notable and would be marked. Please take your time…

Nutritional Informed Consent

According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term "DRUG" is defined to mean: "Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease."

A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy.

Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone.

Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.

Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the client’s diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body.

Health Practitioner Status PLEASE READ CAREFULLY BEFORE SIGNING:

1. I understand that Debi Foli is not a licensed medical doctor or psychologist. I am not consulting with Straight Nutrition or Debi Foli either in person, through written or electronic means, or through the phone for the purpose of medical diagnosis or psychological evaluation. I am here on this or any subsequent occasion strictly for the purpose of obtaining non-medical natural healing arts services, alternative or complementary healing arts services as defined by the State of California.
2. I understand that Debi Foli attained her Bachelor of Science degree in Natural Health/Business after attending Charter Oak State College, Arizona State University, California State University at San Marcos and others. Debi Foli is a Certified Nutritional Consultant (CNC), a diplomat member in good standing of the American Association of Nutritional Consultants. Debi is a Registered Naturopathic Diplomat (RND) and Traditional Naturopath (NP). She is a Certified Member of the National Provider Network for Professional Athletes with GotProHealth. In her training she studied anatomy, physiology, chemistry, biology, nutrition and disease, naturopathic toxicology, blood chemistry, saliva testing, herbology, homeopathy, tissue and cellular detoxification, biology of cancer, endocrinology, contemporary ethics in health care, regulatory and accrediting agencies in health care, and medical terminology. Board Certifications: American Association of Drugless Practitioners (AADP) and American Alternative Medical Association (AAMA).
3. I understand that the theory of care upon which the services Straight Nutrition offers is based in combination upon: Naturopathic Theory of Toxicology and Detoxification, Homeopathic Theory (like-cures-like), and/or Internal Nutritional Balancing utilizing a non-medical, non-drug approach to health.
4. I understand that Debi Foli/Straight Nutrition is not advising me to forego the use of prescribed medications or any medical treatment, be it surgery, chemotherapy, radiation or other medical diagnostic procedures. I acknowledge that nothing in the teachings or methods of Natural Health or Life Sciences is for the purpose of diagnosing, treating, alleviating, mitigating, curing, preventing, or caring for "disease" in any way or manner whatsoever.
5. I understand that the nature of services offered by Straight Nutrition is strictly restricted to the non-medical areas of health. Any program may include recommendation of nutritional substances such as foods, whole foods for dietary use as defined under federal law, herbs, homeopathic remedies, neutraceutical transdermal creams and the like.
6. The work we shall engage in is only to help balance my body chemistry. Should I be dissatisfied in any manner with the services provided to me by Straight Nutrition or its staff, I shall promptly bring it to the attention of Debi Foli, CEO/President, so it can be properly discussed and remedied.
7. I understand that I am responsible for all charges incurred. I acknowledge that payment is due when services are rendered. Every unkept appointment can prevent someone else from receiving services. If you must cancel an appointment, please do so within 48 hours or you will be charged the usual and customary fee for services.
8. I understand that Debi Foli is not a Naturopathic Physician or Nurse Practitioner and legally offers her services as a Naturopathic Practitioner and Certified Nutritional Consultant as described in California State law under the Business and Professions codes 3645, 2053.5 & 2053.6.

I have read the above statement and understand the nature of services that I have requested Straight Nutrition to render.

Please review our HIPAA notification. Because email is not considered secure standard for transporting health information, we must notify you that at this time our symptom survey utilizes a standard email to send your health information to our practitioners at Straight Nutrition. We ARE in the process of upgrading our symptom survey to a HIPAA acceptable standard of transport, however, today, your information moves from our secure server to our practitioners via email. By agreeing to the terms of this form, you allow us to receive your health information via email and agree to our HIPAA practices as outlined below.

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

We are very concerned with protecting your privacy. While the law requires that you give us this disclosure, please understand that we always will, respect the privacy of your health information.

There are several circumstances in which we may have to use or disclose your health information.

1. We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
2. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.
3. We may need to use your health information within our practice for quality control or other operational purposes.
4. We may have to disclose your health information to Science Based Nutrition or other labs to obtain test results and reports.

We reserve the right to change our privacy practices as new regulations occur. If we make a change to our privacy practices, we will notify you in writing when you come in for nutritional consultation. Please feel free to email us at any time for a copy of any privacy notices. You may also find them in our website at the bottom of the page.

I authorize Straight Nutrition to contact me with information related to my health needs and interests. Straight Nutrition’s staff may use any phone number or email in my personal records to contact me. If contact is made by phone and I am unable to respond, a message may be left with my home answering machine or voice mail service. I may be contacted about the following:

• Appointment reminders or schedule change
• Information about alternative nutritional plan, presentations or events
• Other health related information that may be of interest to me

To contact me, I authorize Straight Nutrition to use and disclose the following information:

• My Name, Address, Email and Phone Numbers
• The Name of my Practitioner and the Center where I was seen

NOTE: NO DIAGNOSIS OR NUTRITIONAL PLAN INFORMATION WILL BE USED OR DISCLOSED.

Straight Nutrition fully supports the protection of health information. Only the practitioners and office staff will use this information to contact you. While we retain the standard rights of disclosure as provided under HIPAA, this authorization allows us to access only the authorized information for contact purposes.

This authorization will remain valid for ten (10) years from the date of signature. You may revoke this authorization at any time or request to receive a copy of the protected health information to be used by writing to Straight Nutrition – 210 S. Vine St., Fallbrook, CA 92028. In this case, every effort will be made to discontinue future communications.