Marcy Kirshenbaum, MS, CCN, CNS, LDN/Enhance Nutrition, LLC
NUTRITIONAL CONSULTING INFORMED CONSENT AND DISCLAIMER FORM
GOAL: The basic goal of Enhance Nutrition is to encourage clients to become knowledgeable about and
responsible for their own health, and to help them to reach a personal, optimum level of healthiness
through nutrition and supplement related education and counseling. Achieving the goal of optimum
health, absent other non-nutritional complicating factors requires a sincere commitment from you,
possible lifestyle changes, and a positive attitude. There is no guaranty that you will achieve your goal,
but Enhance Nutrition will make every effort to work with you on that objective.
I will evaluate your nutritional needs and current dietary habits/consumption and make suggestions
regarding dietary changes and, if warranted, the introduction of nutritional supplements to your daily
routine. I may use laboratory analysis to help me investigate your nutritional needs. I am not trained to
provide medical diagnoses, and no comment or suggestions should be construed as being a medical
diagnosis. While some of my work and suggestions may focus on your current or past medical
conditions, I am only providing nutritional advice and will NOT be providing any medical advice of any
kind whatsoever. Since every human being is unique, I cannot guarantee any specific result or outcome
from my suggestions. Obviously, to the extent that my advice is not followed or followed in a limited
manner, results may vary.
HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with
an appropriate healthcare provider. Consulting with me is not a substitute for being treated by your
primary-care provider or other appropriate healthcare practitioner. I am not trained or licensed to diagnose
or treat pathological conditions, illnesses, injuries, or diseases. If, through our sessions, I am made aware
of the existence of certain medical conditions, illnesses, injuries or diseases that may afflict you, I plan to
incorporate that knowledge into my suggestions to the best of my ability. Nutritional advice is no
substitute for medical care and is only a complement to the care you receive elsewhere.
If you are under the care of another healthcare provider, particularly if you are currently taking
prescriptions as a part of such care, it is vitally important that you promptly contact your other healthcare
provider(s) and alert them to your use of nutritional supplements. Enhance Nutrition cannot be
responsible in any way for such communication. Nutritional changes you may choose to undertake and
the use of supplements in connection therewith may be a beneficial adjunct to more traditional care, and it
may also alter your need for or the required dosage of your medication, so it is important you always keep
your physician informed of changes in your nutritional program throughout our consulting relationship.
Only your physician can make adjustments to prescription medications.
If you are using medications of any kind, you are required to alert me to such use, as well as to discuss
any potential interactions between medications and nutritional products with your pharmacist. If you have
any physical or emotional reaction to nutritional therapy, discontinue use immediately and contact me to
ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the
therapy. If during our business relationship you are adding, reducing or in any way changing medicine
dosages, it is incumbent upon you to notify Enhance Nutrition promptly so that any necessary
adjustments can be recommended and made.
COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how
your system will react to the supplements you need and the dietary changes that may be suggested. It is
sometimes necessary to adjust your program as we proceed until your body can begin to properly accept
products geared to correct any imbalance that may result. It is recommended that you stay in contact with
me so I can be updated on any changes you’re experiencing particularly negative ones. Please suggest to
your other healthcare provider(s) to contact me via email or telephone with any questions they may have
regarding your nutritional protocol. In addition, I am available for in person or telephone consultations
with you and your healthcare provider(s) upon request.
Nutritional consulting and the costs associated with supplements may not be covered by insurance and all
costs are the sole responsibility of the client. Enhance Nutrition will not be submitting any reimbursement
requests or have any contact with any insurance company for any reason. Enhance Nutrition’s fee and the
cost of supplements may qualify for certain employee Section 125 or related plans. Please check with
your employer for details. In any event, it is the expectation of Enhance Nutrition that payment will be
made by you at the time of any session or prior to the delivery of any supplements, whether in person or
through other means.
By my/our signature(s) below, I/we confirm that I/we have read and fully understand the above
disclaimer, am/are in complete agreement therewith and do freely and without duress sign and consent to
all terms, conditions and admonitions contained herein. Moreover, I/we agree to indemnify and hold
harmless Enhance Nutrition and Marcy Kirshenbaum from and against any loss or cost of any kind
whatsoever relating to my/our execution of this document and the terms contained herein.