Who we are
Suggested text: Our website address is: https://mybrightnutrition.com.
My Bright Nutrition LLC
Client Intake, Informed Consent & Release of Liability
Nutrition Counseling Services – Telehealth (Florida, USA)
Client Information
(Collected as required form fields)
- Full Legal Name
- Email Address
- State/Country of Residence
- Date of Birth
Health Disclosure (Required)
I confirm that I have disclosed all relevant information regarding my health, including but not limited to medical conditions or diagnoses, surgeries (including bariatric surgery), medications, hormones, dietary supplements, and care by a physician or licensed medical provider.
☐ Yes ☐ No (If “No,” I confirm no relevant conditions apply)
I understand that nutrition services rely on the accuracy and completeness of the information I provide.
Scope of Services & Nature of Nutrition Counseling
My Bright Nutrition LLC provides nutrition counseling and education only, delivered via telehealth.
Services:
- do not include medical diagnosis, disease treatment, or medical management,
- do not replace care from a physician or licensed healthcare provider,
- do not provide emergency services,
- do not guarantee outcomes or results.
All recommendations are educational, optional, and implemented at my discretion.
Participation does not create a physician–patient relationship.
Sports & Performance Nutrition Disclaimer
Sports and performance nutrition services are educational in nature and may include guidance on fueling, hydration, supplementation, and recovery.
They do not include physical training plans, exercise prescriptions, fitness assessments, or medical clearance for athletic participation.
I understand that athletic participation carries inherent risks and requires appropriate medical screening independent of nutrition counseling.
Telehealth Consent
I consent to receive services via telehealth and electronic communication.
I understand that:
- no physical examination is performed,
- services rely on self-reported information,
- technology failures may occur,
- electronic communication cannot be guaranteed to be fully secure.
I understand that telehealth may not be appropriate for all conditions.
Emergency Notice:
Telehealth nutrition counseling is not appropriate for emergencies.
In urgent situations, I will contact 911 (U.S.) or my local emergency number.
Risks & High-Risk Acknowledgment
I acknowledge that nutrition counseling may involve risks, which may be increased for individuals with certain conditions or circumstances, including but not limited to bariatric surgery history, diabetes or blood sugar disorders, eating disorder history, pregnancy or postpartum status, renal, cardiac, or hormonal conditions, anticoagulant use, endurance or high-intensity training, and dietary supplement use.
I knowingly and voluntarily assume all such risks.
Client Responsibility
I agree to provide accurate information, inform My Bright Nutrition LLC of health changes, consult my physician as needed, discontinue recommendations if symptoms occur, and assume responsibility for decisions related to my health and performance.
Release of Liability & Indemnification
To the fullest extent permitted by Florida law, I voluntarily assume all risks associated with participation in nutrition counseling services.
I release, waive, and hold harmless My Bright Nutrition LLC, its owner, employees, contractors, and agents from any claims arising from participation in nutrition counseling services, including claims alleging negligence, except where prohibited by law.
I agree to indemnify and hold harmless My Bright Nutrition LLC from claims arising from inaccurate information, failure to seek medical care, or misuse of nutrition recommendations.
Payment & Cancellation Policy
- Self-pay only; insurance not accepted
- Payment required in advance
- Payments are non-refundable unless required by law
- Appointments cancelled or rescheduled with less than 24 hours’ notice may be charged
Confidentiality & Privacy
Reasonable safeguards are used to protect personal and health information.
I acknowledge the inherent privacy risks of electronic communication.
Governing Law
This Agreement is governed by the laws of the State of Florida, USA.
If any provision is unenforceable, the remainder remains in effect.
Electronic acceptance constitutes a legally binding signature.
Acknowledgment & Consent (Required)
☐ I confirm I am 18 years of age or older
☐ I have read, understand, and agree to this Agreement
Typed Full Legal Name (Electronic Signature)
Date (auto-filled)
