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Health questionnaire and telemedicine consent
Please complete this form and return it 48 hours prior to your appointment via email. This information will be stored in accordance with our Privacy Policy. You can change your preferences at any point by contacting Nutrition 2 Nourish & Flourish at E:
nutrition2nourishflourish@gmail.com
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Full Name
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Email
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Phone
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I give consent for Nutrition 2 Nourish & Flourish to carry out telemedine appointment/s and contact me regarding my treatment. I would prefer to be contacted by:
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Telephone
I have read and agree to the telemedicine consultation terms at
https://nutrition2nourishflourish.com/telemedicine-consultations-terms/
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No
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We would like to contact you about their services. I am happy to be contacted for marketing purposes. (You can unsubscribe at any time) If you consent to direct marketing, how would you like to be contacted:
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I have read and agree to the terms and conditions found at
https://nutrition2nourishflourish.com/terms-and-conditions/
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No
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