ALINANUTRITION - Terms of service and consent

Alina Petre, MSc, RD
Canadian-registered dietitian
OPDQ registration # 4785
KvK: 63298872
BTW: NL309170138B01
info@alinanutrition.com

This form describes detailed information regarding your rights and responsibilities as well as the established policies of AlinaNutrition's counselling practice and all nutrition counselling services provided by Alina Petre, MSc, RD. Please read each section carefully.

Appointments:

I agree to make every effort to keep all schedule appointments and to be on time. If I cannot attend a scheduled session, I will email info@alinanutrition.com to cancel and/or reschedule.

There will be no fee if my email is received before 2pm the day prior to your appointment. For appointments scheduled on Monday, my email should be received prior to 2pm the previous Friday.

If my email is received after this time, I will be responsible to pay 50% of the fee of my nutrition session.

Initial appointments are 90 minutes and follow up appointments are 60 minutes. They can take place in person, at AlinaNutrition's office (Jansdam 2a, 3512HB, Utrecht, Netherlands), by phone or by video-conference.

I have been informed that Alina Petre MSc, RD has the right to terminate services offered with a 30 day written notification given to me with a listing of referrals for continuity of care.

Confidentiality:

I understand that no information about my treatment will be released to anyone unless I provide written authorization.

The only exception is if I have not paid for services and my information is sent to collections for payment; then necessary information will be released in order for Alina Petre MSc, RD to obtain payment for service.

I also understand that there are limits to my confidentiality, including the following:

• Where there is the risk of imminent harm to myself or another person; Alina Petre MSc, RD has the legal and/or ethical duty to take the appropriate steps to protect life.
• When a court orders AlinaNutrition to release information; Alina Petre, MSc, RD is bound by law to comply.
• When AlinaNutrition has reason to believe that a child or an elderly person is in danger of or is being abused (physically, emotionally, or
sexually), Alina Petre, MSc, RD is obligated by law to report the abuse.
• In response to a subpoena from a court of a law or a secretary

Email:

I understand that email is not a confidential method of communication and that phone or in- person contact is the best way to communicate personal information.

I understand that Alina Petre, MSc, RD customarily checks email but does not guarantee immediate response to email.

I also understand that there are instances where e-mail is sent but never received. For these reasons, phone or in-session contact is the preferred method to ensure confidentiality and a timely response.

Fees and Financial Agreement:

AlinaNutrition's fees: 90 minute initial session = €135.00
60 minute follow-up session = €90.00

Payment is due in full within 14 days of receipt of the invoice unless a different instalment schedule has been previously agreed-upon with Alina Petre, MSc, RD.

I am aware that I benefit from a rebate if I decide to purchase a nutrition package. This nutrition package can be cancelled anytime and I remain eligible for a refund on the unused portion of my package. This refund will, however, be performed only after re-calculation of the used portion of my package using the standard rate per session currently in force.

Further details on the appointment cancellation policy are outlined above. Forms of payment accepted include: cash, bank transfer, Paypal and credit card.

Insurance companies often cover nutrition counselling services as an out-of-network benefit. If I choose to attempt reimbursement from my insurance company for Alina Petre, MSc, RD's services, the billing is my responsibility.

Alina Petre, MSc, RD will provide a signed receipt for each nutrition session that I can submit to my insurance company for possible reimbursement.

I have the responsibility to research this option on my own. I understand that Alina Petre, MSc, RD does not guarantee reimbursement, rather is suggesting this is a possibility and is willing to help me expedite the possibility.

Counselling Process and Your Rights Regarding Treatment:

I understand that Alina Petre, MSc, RD and I will work together to define my goals for nutrition counselling. Since nutrition counselling is not an exact science, I understand that the results of counselling may vary.

I understand that the attainment of a positive outcome is dependent upon the effort expended by both Alina Petre, MSc, RD and myself. I am willing to put my part into this experience.

I understand that I have the right to ask questions about my counselling. I have a right to choose a Registered Dietitian who best suits my needs. I also have the right to end my counselling at any time and understand that I should notify Alina Petre, MSc, RD when I am finished.

If I decide that I would like to continue my nutrition counselling with another professional, Alina Petre, MSc, RD can facilitate that process.

I understand that Alina Petre, MSc, RD reserves the right to refer me to another professional if the level of care provided by AlinaNutrition is assessed by Alina Petre, MSc, RD to be inappropriate or for any other reason.

Complaints:

I understand that if I have concerns about my treatment I can talk directly with Alina Petre, MSc, RD about these issues.

I also understand that if I want more information about the code of ethics for dietitians or want to file a complaint I can contact: The Ordre Professionel des Diététistes du Québec (OPDQ) at www.opdq.org.