In order to proceed, I would be grateful if you could complete this online Terms of Agreement and Consent Form.

This form must be filled out before the consultation takes place. Please notify me once completed. Thank you

Please Also Note: A copy of your completed form once submitted at the end will be emailed to you automatically using the email address you supply.

A NOTE ON TERMINOLOGY: Throughout this document and appendices the Term ‘GP’ or ‘Medical Doctor’ is used – in the UK and some other locations ‘GP’ means ‘General Practitioner’ and refers to a Medical Doctor. In other locations where the terms General Practitioner or GP are not used then the equivalent is usually Medical Practitioner or Medical Doctor.

Part 2

Boundaries and Scope of the Nutrition & Body Composition Assessment consultation

  • The Nutrition & Body Assessment is an application of nutrition to empower clients to make informed decisions about their nutrition.
  • The Nutrition & Body Assessment allows people without significant health complaints to receive general information about nutrition and lifestyle.
  • The Nutrition & Body Assessment also has a potential for prevention and might help to burst myths around nutrition.
  • The Nutrition & Body Assessment may be time-saving as many nutritional therapy clients will benefit from general education before delving into personalisation.
  • During a Nutrition & Body Assessment consultation, there is no suggestion that the client should follow, it is all about the client’s choice after receiving the information.
  • The Nutrition & Body Assessment is not suitable for very ill people who may need to make very small specific changes after being very clear as to what is going on.
  • People who are already eating quite well may want answers as to why they are still struggling with their health and during a Nutrition & Body Assessment, these answers cannot be.
  • During a Nutrition & Body Assessment, are never provide personalised advice. Nor will be suggested supplements or testing recommendations.

The Client understands and agrees to the following:

• I am responsible for contacting my GP about any health concerns.

• It is important that I tell my RNTP about any medical diagnosis, medication, herbal medicine or food supplements I am taking.

• Recording consultations using any form of electronic media is not allowed without the written permission of both me and my RNTP.

• It is my responsibility to ensure I have a working internet connection for online appointments. If I am unable to connect as scheduled, the appointment is considered a ‘no show’ and charged in full.

Susanna Fall Nutritional Medicine consultant & Pharmacist requests that the Client notes the following:

When providing this service, Susanna Fall Nutritional Medicine consultant & Pharmacist provides a service as an RNTP. During the consultations, any advice and suggestions provided by Susanna Fall are given as a RNTP.
Susanna Fall is not a conventional medical doctor (GP), and she is not practising as a pharmacist when working in her clinic.
Any suggestions or advice given by Susanna Fall is not a replacement for medical advice.

The RNTP requests that the Client understands and agrees to the following:

  • I agree for the RNTP to contact my medical practitioner if considered necessary and/or make referrals to qualified health practitioners. I understand that the consultation will not proceed without this agreement. If at the end of the consultation, I decide that I would like to withdraw approval for my medical practitioner or other health practitioners to be contacted, then the consultation will be considered null and void, and no further communication from the Susanna Fall will be made. I understand that if my medical practitioner is in a private practice then charges may be made by them to read any correspondence sent, and if required, I will cover the cost.
  • I understand that the RNTP has a legal duty of care while I am a client. I understand that occasions could arise when the RNTP would be legally obliged and/or required by the Professional and Regulatory Code to communicate with other professionals/agencies including my GP without my explicit consent. Should such an unlikely but possible situation arise I acknowledge that I would be informed that contact was to be made, and where legally allowed the content of such communication would be made available to me.
  • I agree to record my dietary intake as requested and complete the Health Check Questionnaire four to five days before the consultation so that the RNTP has time to analyse my diet and review the questionnaire in advance of the consultation.
  • I confirm that the information provided by me on the Health Check Questionnaire and during the consultation process is and will be, to the best of my knowledge, true and accurate.
  • During face to face consultation, weight measures might be taken (only shoes and socks may need to be removed).
  • I must tell my RNTP about any medical diagnosis, medication, herbal medicine, or food supplements I am taking.
  • The RNTP reserves the right to determine which cases fall outside her scope of practice, in which circumstance the appropriate referral will be recommended.

Confidentiality and Data Protection

The Registered Nutritional Therapy Practitioner will keep your personal information confidential and secure following the GDPR guidelines for the practice. The RNTP will not share your information with third parties without your consent. However, if the RNTP believes there is a risk of significant harm to yourself or another person, the RNTP may pass the information onto an appropriate authority using the legal basis of vital interest. A separate Privacy and Consent Notice is available for your review.

Part 3

Payment Terms and Cancellation Policy

Fees are agreed upon in advance of the appointment and are paid in full at the time of the appointment’s booking or when online booking is not available 48 hours in advance of an appointment. Payments can be made by bank transfer, credit or debit card.

Appointments cancelled with less than 48 hours’ notice will be charged in full.
Should you cancel the Nutritional & Body Assessment consultation after effectuating the booking, but before the 48 hours’ notice, we will issue a refund minus a maximum £30.00 admin fee.

Sessions must be used within six months of the purchase date.

In the case of advance payments for services, you have the right to cancel this Agreement within 14 days of the purchase without penalty (‘Cooling-off Period’). If you wish to terminate the agreement within the 14-day Cooling-off Period, you must do so in writing to info@susannafall.com. The RNTP will refund any money paid prior to cancelling this Agreement minus a maximum £30.00 admin fee. If the services have commenced during the 14-day Cooling-off Period, the RNTP will refund any money due to you for services not yet provided. The refund payment will be made within 14 days of cancellation.

Part 4

A Consultation can only proceed if the above Terms of Engagement are accepted. You will not be able to progress within this form without confirming below. If you wish to clarify any point before proceeding you can contact me at info@susannafall.com and I will aim to provide you with the clarification/s requested. We understand the above and agree that our professional relationship will be based on the content of this Agreement. We declare that all the information we share during this professional relationship is confidential and to the best of our knowledge is true and correct.

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