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I hereby consent to receive medical nutrition therapy, nutrition education and/or counseling. I understand that any medical information maintained by the registered dietitian will not be available to any person or entity without a current authorization for release of information given by me. I further understand that any information regarding my health status shall be maintained confidentially and will not be disclosed except in aforementioned instance. I understand nutrition counseling is not a substitute for diagnosis, treatment, or care of disease by a medical provider. Furthermore, I will not hold the registered dietitian liable for any illness or injury that may occur as a result of carrying out any prescribed health/nutrition programs.