Client Consent Form

The physician that I see most regularly is:

City and State of Physician's Office:

Do you prefer to be reminded of your appointments via telephone call, text or email?

Please provide the phone number or email address you prefer we use:

Can we connect with you via social media outlets? (i.e. Facebook)

Would you be interested in providing any feedback about your experience with Nutriworks in the future?


BY ENTERING MY NAME BELOW, I ASSERT THAT I HAVE REVIEWED AND AGREE TO ALL OF THE ABOVE STATEMENTS.

Please indicate that you are an actual person completing this form: