Nutrition Consultation Request Form

Name Name First Last
Email
Phone Phone - ### - ### ####
I would prefer to meet:

I would prefer to meet: In-Person Virtually (Microsoft TEAMS)
I would like to request a Nutrition Consultation for the following:

I would like to request a Nutrition Consultation for the following: Weight Management Weight/Fat Loss Weight/Muscle Gain Sports or Performance Nutrition Medical Nutrition Therapy Skin Nutrition Eating Disorder/Disordered Eating Wellness/Preventative Nutrition Basic Nutrition Education
Please note that you must purchase an Initial Nutrition Consultation which includes two sessions with our dietitian. This is a $50 commitment. Additional sessions may be purchased on an as needed basis at a rate of $25 each. The Assistant Director for Wellness will put you in contact with the dietitian and provide additional instructions via email upon receipt of this form. Should you have any other questions or have additional information you would like to share with us, please use the space below.
WAIVER AND RELEASE FOR NUTRITION COUNSELING

I acknowledge that I am aware that the University of Texas at Arlington’s Department of Campus Recreation, its members, officers, agents, and employees are not medical doctors and do not diagnose disease. I also acknowledge that I have been warned that I should consult a Physician before undergoing any dietary or food supplement changes. I also affirmatively state that I will disclosed any and all known medical or genetic conditions, medications I use, and any significant personal or family medical history. Any recommendations that I follow for changes in diet, including but not limited to the use of food supplements, are entirely my choice and my responsibility. I am knowingly assuming any risk associated with nutritional counseling.

In consideration of my participation in nutrition counseling, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release the University of Texas at Arlington’s Department of Campus Recreation, its members, officers, agents, and employees from any liability whatsoever to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness, injury or other harm to my person, including my death, that may result from or occur during my participation in nutrition counseling, whether caused by the sole or concurrent negligence of the University of Texas at Arlington’s Department of Campus Recreation, its members, officers, agents, and employees.

I further agree to indemnify and hold harmless the University of Texas at Arlington’s Department of Campus Recreation, its members, officers, agents, and employees, to the fullest extent permitted under law, from any and all liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described nutrition counseling session.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN NUTRITION COUNSELING AND OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMMISSION.

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