© Copyright [THE WHOLESOME THERAPIST] 

[THE WHOLESOME THERAPIST] INFORMATION FORM (CONFIDENTIAL)

Informed Consent for [NUTRITIONAL THERAPY] with 

[ALIFIA LOKAT, DipNT, mANP, rGNC & NLP]

[NUTRITIONAL THERAPY] is practiced by non-medical professionals and is complimentary to other regulated forms of healthcare in England. Consultations with a [NUTRITIONAL THERAPIST] include taking a detailed case history, performing a physical exam if relevant, creating a [NUTRITIONAL DIET & LIFESTYLE PLAN, WHICH MAY INCLUDE SUPPLEMENTS AND FURTHER TESTING, AND ALSO CORRESPONDENCE WITH YOUR GP WHERE REQUIRED], and following up on results and progression of your health. [THE WHOLESOME THERAPIST / NUTRITIONAL THERAPY] employ a range of therapeutic techniques including [DIETARY & LIFESTYLE ADVICE, SUPPLEMENTS, TESTING and REFERRALS FOR HERBAL MEDICINE WHERE REQUIRED].  

While the best course of action is continually sought for the patient there always exists the possibility of side effects, adverse reactions or inefficacy of treatment. [THE WHOLESOME THERAPIST] holds your safety and well-being as [HER] top priority in the management of your case and welcomes all questions or concerns you may have.

In signing below I, ________________________________, acknowledge that:

• [ALIFIA LOKAT / THE WHOLESOME THERAPIST] has in no way suggested that my being under HER care should prevent me from seeking treatment from any other healthcare practitioner.

• [ALIFIA LOKAT / THE WHOLESOME THERAPIST] will strive to deliver the safest and most effective interventions for my case, however there is still the possibility that side effects or adverse reactions might occur, or that therapeutic benefit may not be achieved.

• I will inform [ALIFIA LOKAT / THE WHOLESOME THERAPIST] of all medical conditions I have been diagnosed with, symptoms I am experiencing, and medications I am taking/have taken in the past. I will also inform HER of any new medical conditions or symptoms or medications should they arise.

• I will inform [ALIFIA LOKAT / THE WHOLESOME THERAPIST] if I am pregnant or breastfeeding. I will immediately inform HER should I become, or plan to become pregnant or if I begin, or plan to begin to breastfeed.

• I will inform [ALIFIA LOKAT / THE WHOLESOME THERAPIST] if I do not understand any given part of the recommendations given to me or if I am uncomfortable with any aspect of my care.

• All of the information I provide to [ALIFIA LOKAT / THE WHOLESOME THERAPIST] and protected by General Data Protection Regulations and is confidential unless disclosure is required by law.

• My case information may be used for the publication of case reports or case studies. Any information concerning my identity will be excluded from publication, thus maintaining my anonymity.

• I am free to purchase any products recommended by [ALIFIA LOKAT / THE WHOLESOME THERAPIST] for my treatment from a vendor of my choosing, being under no obligation to purchase products from [ALIFIA LOKAT / THE WHOLESOME THERAPIST] directly.

• I have read and understand [ALIFIA LOKAT / THE WHOLESOME THERAPIST] fee and prices schedule*.

I declare that I have read and understood the information presented above and that I authorise and consent to my present and future use of the [NUTRITIONAL THERAPY] services by [ALIFIA LOKAT / THE WHOLESOME THERAPIST]. I understand that I may withdraw this consent at any time.  

[NUTRITIONAL THERAPY] Consultation & Cancellation Policy

• Cancellation Policy - cancellations not reported 24hrs prior to an appointment will incur a cancellation fee of £40.

• Consultation Payments - therapy payments will be invoiced to the client prior to the appointment. Payment is to be made 48hrs before consultation. Without this, we regret we are unable to proceed with the consultation.

• Payment can be made in 3 interest free instalments, which can be discussed during the free health review.

• Additional Costs - Any recommendations for supplements, herbal medicine or further testing are not included in the consultation fees. Therefore, these will be additional costs, which you will be informed about during your consultation. Although these may be beneficial to your therapy, you are not obliged to proceed with these recommendations.