NAME

E-MAIL ADDRESS

PHONE NUMBER

Medications and/or vitamin supplements you currently take and other or additional information you need us to know about you

Weight Reduction

Diabetes or Insulin Resistance

Cholesterol or triglycerides

Blood pressure

Renal/kidney stones

Renal/kidney disease

PCOS

Lactose intolerance

Gluten sensitivity

Celiac

Crohns/Colitis

IBS (Irritable Bowel Syndrome)

Need to gain weight

PENNSYLVANIA LOCATIONS

NAME OF HEALTH INSURANCE COMPANY

I have read and agree to the terms and conditions listed below:

HIPPA Notice of Information Practices

How We Collect Information About You: Diamond Nutrition Counseling, LLC and its employees/contractors/associates and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of applications that is either required by law, or necessary to process applications or other requests for assistance through our organization.

What We Do Not Do With Your Information: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence.

We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered patient confidential, is restricted by law, or has been specifically restricted by a patient/client in a signed HIPAA consent form.

How We Do Use Your Information: Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between our providers and other health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to: verify your medical information is accurate; determine the type of medical supplies or any health care services you need including, but not limited to; or to obtain or purchase any type of medical supplies, devices, medications, insurance, and counseling.

If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.

Information We Do Not Collect: We do not use cookies on our website to collect data from our site visitors. We do not collect information about site visitors except for one hit counter on the main index page (www.diamondnutritioncounseling.com) that simply records the number of visitors and no other data. We do not use affiliate programs. To avoid potential data capture that you visited another via our website, simply do not click on any of our outside affiliate links.

Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources: Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of Diamond Nutrition Counseling, LLC. We reserve the right to use non-identifying information about our clients (those who receive services or goods from or through us) for fundraising and promotional purposes that are directly related to our mission.

Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client’s express advance permission.

You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent.

User Agreement Regarding Online Advice Service

This is a legal agreement between you the Customer and diamondnutritioncounseling.com hereinafter referred to as Consultant, and states the terms that govern your use of the Consultant’s (the Website) and any services or information provided to you by Consultant. By using the Website, and/or by receiving services or information provided by Consultant, you agree to comply with and be bound by these Terms of Use (this Agreement). This Agreement is subject to changes, updates and additional terms, rules and polices, which are effective upon posting on the Website. You agree to be bound to any changes to this Agreement when you use the Website or receive any services or information from Consultant after the changes are posted. IF YOU OBJECT TO ANY TERMS OF THIS AGREEMENT OR ANYTHING IN THE WEBSITE, DO NOT USE THE WEBSITE. DO NOT RECEIVE OR ACCEPT ANY SERVICES OR INFORMATION FROM CONSULTANT.

Services of Consultant

Consultant is an online and in-office resource to provide nutrition counseling advice. Services offered through the Website or our offices for private counseling are limited to providing email/live chat or real-time face-to-face in-office responses containing advice to the average adult, on nutrition-related issues such as dietary advice to help you manage your nutrition concerns (the Services). Only adult Customers/Patients (18 years or older) may use the Services. A Customer/Patient seeking advice can submit an online or phone description of his or her issue and purchase the Services offered through the Website or in-person. Nutrition counseling Services will be provided by Consultant.

Eligibility and Security

Your use of the Website is void where prohibited. CONSULTANT SHALL USE REASONABLE EFFORTS TO PROTECT INFORMATION YOU SUBMIT IN CONNECTION WITH THE WEBSITE, BUT YOU ACKNOWLEDGE AND AGREE THAT YOUR SUBMISSION OF SUCH INFORMATION IS AT YOUR SOLE AND EXCLUSIVE RISK, AND CONSULTANT SHALL NOT HAVE ANY LIABILITY TO YOU FOR ANY LOSS OR DAMAGE RELATING TO DISCLOSURE OF SUCH INFORMATION. SEE NOTICE OF HIPPA AND INFORMATION PRACTICES WHICH FOLLOWS THIS AGREEMENT.

Prohibited Use

You may not use the Website in connection with any commercial activity or for financial gain unless Consultant has given its written consent to such use. Any use of the Website to collect visitor's email addresses, by electronic or other means, for the purpose of sending unsolicited commercial email, spam or computer viruses is an unauthorized use of the Website. Consultant reserves the right to undertake legal action for any illegal and/or unauthorized use of the Website.

Customer Acknowledgement

The Customer hereby acknowledges and agrees that:

  1. Consultant's Advice Consultant has no formal education, training or experience in the evaluation, assessment, diagnosis, treatment and prevention of emotional and mental disorders and behaviors. Consultant is not a licensed psychologist, mental health counselor, social worker, marriage or family therapist, or doctor.
  2. Consultant's Services do not include evaluation, assessment, diagnosis, treatment or prevention of any emotional or mental disorders or behaviors.
  3. The Services provided by Consultant are limited to providing email responses to questions or issues posed by a Customer who has paid in advance for the Services.
  4. The links provided on this Website are for informational purposes only. Consultant does not warrant the accuracy, completeness or quality of any information contained on websites owned or maintained by third parties.

Customer's Responsibilities, Representations and Warranties

  1. The Customer shall not request from Consultant any evaluation, assessment, diagnosis, treatment or prevention of any emotional or mental disorders or behaviors.
  2. In the event of any emergency, the Customer shall dial 911 or contact their local emergency room or a licensed mental health professional.
  3. The Customer shall provide confidential or private information to Consultant, of Customer’s choice which may be relevant to counseling session by accepting the policies and agreements relevant to this website before counseling sessions begin, i.e. current document, HIPPA waiver, and Notice of Information Practices document. The Customer fully assumes the risk of disclosure of any confidential or private information provided to Consultant.
  4. The Customer shall pay for the Services in advance.

Consultant's Rights

Consultant reserves the right to remove, block and/or delete your information from its database without warning if you violate this Agreement. Consultant reserves the right to take any action that Consultant deems in its sole and absolute discretion reasonably necessary or appropriate to enforce and/or verify your compliance with any part of this Agreement and to cooperate with any legal process relating to your use of the Website, and/or to investigate a third party claim that your use of the Website is unlawful and/or infringes such third party's rights. You agree that Consultant has the right, without liability to you, to disclose any information you provide to any third party, as Consultant deems, in its sole and absolute discretion, reasonably necessary or appropriate to enforce and/or verify compliance with any part of this Agreement, to cooperate with any legal process relating to your use of the Website, and/or to investigate a third party's claim that your use of the Website is unlawful and/or infringes such third party's rights. Consultant reserves the right to reject and refuse to accept any information you provide, and to delete, remove or edit any information you provide any time, for any reason, in Consultant's sole and absolute discretion and without prior notice or liability. Consultant reserves the right, in its sole and absolute discretion, to restrict, suspend, or terminate your access to all or any part of the Website at any time, for any or no reason, with or without prior notice, and without liability. You agree that Consultant may store and use the information you provide (including PayPal account information) for its own use in maintaining your account and billing fees to your PayPal account.

Consultant's Content

Consultant owns and retains all proprietary rights in the Website, which contains copyrighted text, information, video recordings, audio recordings, works of authorship and images created by or on behalf of Consultant, trademarks, and other proprietary information and intellectual property of Consultant and its licensors (Consultant Content). Except for that Consultant Content which is in the public domain, for which Consultant or its licensors have given you express written permission, you may not license, transfer, copy, modify, publish, transmit, distribute, display, or sell any such Consultant Content.

Authorization, License and Release

You unconditionally authorize and grant Consultant the non-exclusive authority, right and license to publish, distribute, display and commercially use your initials and information you submit to the Website, in any media, whether print, audio, video, radio, television, film or internet, in and on the Website, and to promote, advertise or publicize the Website. You forever release, on behalf of yourself, your heirs and your personal representatives, Consultant and its shareholders, officers, directors, agents, representatives, employees, assigns, affiliates, successors and any person or entity in privity therewith, of and from any and all claims, lawsuits, damages and actions that you could assert in the future arising from or relating to this Authorization, License and Release including, without limitation, claims for royalties, trademark/copyright infringement, defamation, libel, slander, emotional distress, false light, invasion of right to privacy, infringement on the right to publicity, attorney's fees, compensatory damages and punitive damages.

Copyright Policy

You may not post, publish, distribute, display or reproduce in any way any copyrighted material, trademarks, or other proprietary information without obtaining the prior written consent of the owner of such proprietary rights. If you believe that your work has been copied and posted on the Website in a way that constitutes copyright infringement, please provide Consultant with the following information: an electronic or physical signature of the person authorized to act on behalf of the owner of the copyright interest; a description of the copyrighted work that you claim has been infringed; a description of where the material that you claim is infringing is located on the Website; your address, telephone number, and email address; a written statement by you that you have a good faith belief that the disputed use is not authorized by the copyright owner, its agent, or the law; a written statement signed by you, made under penalty of perjury, that the above information in your notice is accurate and that you are the copyright owner or authorized to act on the copyright owner's behalf.

Computer System Integrity

Consultant does not represent, warrant, guarantee or promise that the Website will be free from loss, corruption, attack, viruses, interference, hacking, or other security intrusion, and Consultant disclaims any liability relating thereto. You are responsible for backing up your own computer system. Consultant is not responsible for any error, omission, interruption, deletion, defect, delay in operation or transmission, communications line failure, change of email address, theft or destruction or unauthorized access to, or alteration of, any Consultant Content or email message. Consultant is not responsible for any problems or technical malfunction of any telephone network or lines, computer online systems, servers or providers, computer equipment, software, failure of any email or account information due to technical problems, change of email address, or traffic congestion on the Internet or on the Website or combination thereof, including any injury or damage to you or to your computer related to or resulting from, in whole or in part, any use of the Website.

Electronic Signatures and Payment

Your use of the Website includes the ability to enter into agreements and/or to make purchases electronically. You acknowledge that your electronic submissions constitute your agreement and intent to be bound by and to pay for such agreements and purchases. You agree to pay for any and all services you purchase through the Website, and that Consultant may charge your PayPal account for any services you purchase, and for any additional amounts (including any taxes and late fees, as applicable) as may be incurred by or in connection with your account. YOU ARE RESPONSIBLE FOR THE TIMELY PAYMENT OF ALL FEES AND FOR PROVIDING CONSULTANT WITH VALID PAYPAL ACCOUNT DETAILS FOR PAYMENT OF ALL FEES. All fees will be billed to the PayPal account you designate. If there is a change in your PayPal account or status, you must change your PayPal account information contained in your account. Consultant may disable or terminate your account until it verifies the validity of the new PayPal account information. Fees and availability of any service are subject to change at any time.

Legal Compliance

The Website is controlled and operated by Consultant from his/her offices in the United States. You agree to comply with all local, state, federal, and national laws, statutes, ordinances, and regulations that apply to your use of the Website.

DISCLAIMERS

CONSULTANT DOES NOT GUARANTEE, REPRESENT, OR WARRANT THAT YOUR USE OF THE WEBSITE WILL BE UNINTERRUPTED OR ERROR-FREE, AND YOU AGREE THAT CONSULTANT MAY DISABLE THE WEBSITE INDEFINITELY OR PERMANENTLY WITHOUT NOTICE TO YOU. YOU EXPRESSLY AGREE THAT YOUR USE OF, OR INABILITY TO USE, THE WEBSITE IS AT YOUR SOLE RISK. THE WEBSITE, AND ANY PRODUCTS AND/OR SERVICES PROVIDED THROUGH THE WEBSITE ARE PROVIDED AS IS AND WHEN AVAILABLE FOR YOUR USE, WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, AND EXCLUDING ALL IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. CONSULTANT DOES NOT GUARANTEE, REPRESENT, OR WARRANT THE QUALITY, MERCHANTABILITY, FITNESS, APPROPRIATENESS, SAFETY OR NECESSITY OF THE INFORMATION ON THIS WEBSITE OR OF THE SERVICES YOU MAY REQUEST. YOU EXPRESSLY AGREE THAT THE INFORMATION PROVIDED ON THIS WEBSITE AND THE SERVICES, OR CONSULTANT'S INABILITY TO PROVIDE THE SERVICES, IS AT YOUR SOLE RISK. THE SERVICES ARE PROVIDED "AS IS" AND "WHEN AVAILABLE," WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, AND EXCLUDING ALL IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. BECAUSE SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES, THE ABOVE EXCLUSION OF IMPLIED WARRANTIES MAY NOT APPLY TO YOU.

Limitation of Liability

In no event shall Consultant, his/her employees, representatives, affiliates, agents, contractors, licensors, successors or assigns be liable for any direct, indirect, incidental, punitive, special, or consequential damages arising from your use of the Website or in-office or online private or group counseling for any other claim related in any way to your use of the Website or in-office counseling, even if Consultant knows of the possibility of such loss or damage. In no event shall Consultant, his/her employees, representatives, affiliates, agents, contractors, licensors, successors or assigns be liable for any direct, indirect, incidental, punitive, special, or consequential damages, including, without limitation, personal injury, wrongful death, disability, pain and suffering, lost wages, lost profits or revenues, arising from your use or receipt of the Website or the online or private in-office counseling Services or any services provided by a third party in relation thereto, even if Consultant knows of the possibility of such loss or damage. In no event shall Consultant's liability to you exceed the total price you pay to Consultant for the Services causing the claimed loss or damage. Because some states or jurisdictions do not allow the exclusion or the limitation of liability for consequential or incidental damages, in such states or jurisdictions, Consultant's liability shall be limited to the extent permitted by law. Your obligations under this paragraph shall survive the termination or cancellation of this Agreement.

Release and Indemnity

By using the Website, you and on behalf of your spouse, domestic partner, heirs, executors, personal representatives, successors and assigns, agree to release Consultant, his/her employees, representatives, affiliates, agents, contractors, licensors, successors, assigns and any person and entity in privity therewith from and against any and all claims for costs, expenses, negligence, personal injuries, malpractice, wrongful death, property damage, lost wages, lost income, attorney's fees, compensatory damages, consequential damages and punitive damages, arising out of arising from or relating to, whether directly or indirectly, in whole or in part, your breach of this Agreement, your use of the Website or in-office counseling services, any act or omission by Consultant with respect to the Services or by any person or entity providing services to you in referral from Consultant. The Customer's obligations under this paragraph shall survive the termination or cancellation of this Agreement. You and on behalf of your spouse, domestic partner, heirs, executors, personal representatives, successors and assigns, agree to indemnify, defend and hold harmless Consultant, his/her employees, representatives, affiliates, agents, contractors, licensors, successors, assigns and any person and entity in privity therewith from and against any loss, liability, claim, or demand, including reasonable attorneys' fees, made, alleged or asserted by any third party due to, arising from or relating to, whether directly or indirectly, in whole or in part, your use of the Website or in-office private counseling services, whether in violation of this Agreement or otherwise, any act or omission by the Customer or the Customer's breach of this Agreement. The Customer's obligations under this paragraph shall survive the termination or cancellation of this Agreement.

Notices

Consultant may send you a notice by sending an email message to the email address listed in your registration or contact information or by sending a letter via United States postal mail to the contact address listed in your registration or contact information. Notices shall become effective immediately.

Governing Law, Venue, Jurisdiction and Mandatory Arbitration

The laws of the State of Pennsylvania and excluding its conflicts of law rules and governs this Agreement and your use of the Website and in-office private counseling services. Your use of the Website and in-office counseling services may also be subject to other local, state, national, or international laws. Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect.

Miscellaneous

This Agreement constitutes the entire agreement between you and Consultant and governs your use of the Website, superseding any prior agreements between you and Consultant. Consultant's failure to enforce any right or provisions in this Agreement shall not constitute a waiver of such provision, or any other provision of this Agreement. If any provision of this Agreement is found by an arbitrator or court of competent jurisdiction to be invalid, the other provisions will remain in full force and effect.

Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations for Diamond Nutrition Counseling, LLC, Nutrition Counseling Specialists of Greater Philadelphia, e-nutritioncounseling.com and/or diamondnutritioncounseling.com 

I understand that as part of my healthcare, this company originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

  • a basis for planning my care and treatment
  • a means of communication among the many health, legal, government or company operations professionals who contribute to and manage my care
  • a source of information for applying my diagnosis and surgical information to my bill
  • a means by which a third-party payer can verify that services billed were actually provided
  • a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

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Pennsylvania locations: Ardmore, Bala Cynwyd, Bucks County, Chestnut Hill, Kennett Square, Limerick, Media, Valley Forge, Washington Square, West Chester and University City