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  • Consent
  • Personal Information
  • Health Questionnaire

Telemedicine Consent

Please read carefully the following consent form.


 

About Our Telemedicine Consultations


 

General Information & Personal Data


General Information about Telemedicine Consultations

I understand that my dietitian wishes me to engage in a telemedicine consultation.

I understand there are potential risks to this technology, including interruptions, unauthorised access and technical difficulties.

I understand that my dietitian or I can discontinue the telemedicine consultation if it is felt that the video conferencing connections are not adequate for the situation.

Use of Personal Data

Your details will be held by Fettle and Bloom Nutrition in line with General Data Protection Regulations (GDPR). Further information on how we use your personal information can be found in our Privacy Policy and Terms & Conditions. Please ensure you have read these before signing this consent form. You can change your preferences at any point by contacting Cristy at cristy@fettleandbloomnutrition.com.

If you no longer wish to hear from Fettle and Bloom, please contact Cristy to unsubscribe from Fettle and Bloom Nutrition communications.

 

Marketing & Communication


 

Contact Information


 

By signing this form, I certify that:

- I have read this form or had this form explained to me;
- I fully understand its contents including the risks and benefits of a telemedicine consultation
- I agree to the information set-out above:

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Personal Information

Thank you, for your consent.

Please now fill out this personal information.
If you wish at anytime to save your progress and fill the rest in at a later point, just click 'save progress'.
This information will be stored in accordance with our Privacy Policy.


Client Health Questionnaire

Thank you, for fill out your personal information.


Please now fill out the following questionnare so Fettle & Bloom can best help you.
If you wish at anytime to save your progress and fill the rest in at a later point, just click 'save progress'.
This information will be stored in accordance with our Privacy Policy.






Thank you, that's everything. Just click 'Submit Questionnaire' below to send to Fettle & Bloom. You'll be then redirected to a page to book your initial consultation with Cristy.

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