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Your Diet Do Over

$497.00Price
Stop Feeling Weight Loss Resistant & Resolve Your GI Issues by joining my 8-Week Program that will show you step by step how to transform the way you live and feel without dieting!

  • Program benefits:

    • Lower or completely "get off" your high-priced prescription medications
    • Heal your Chronic GI issues: constipation, diarrhea, bloating, gas, etc
    • Stop feeling tired and lacking energy
    • Make healthy meals in minutes vs. hours
    • Stop Guessing what foods you should or should not be consuming
    • Stop feeling weight loss resistant

Client Intake Form

Are you the primary insurance holder?
Yes
No
Do you have any food allergies (not sensitivities) that you are aware of?
Yes
No

Please be advised that you (the Client) are responsible for any balance, copayment or deductible that your insurance states you owe. Also, if for any reason you need to cancel a scheduled appointment with less than 48-hour notice, you will be charged a missed appointment fee.

Privacy Consent

We require your consent to use and disclose your protected health information to carry out treatment, payment, and health care operations. If you would like a more detailed description of such uses and disclosures, please refer to the Notice of Privacy Practices.


You have the right to review the Notice of Privacy Practices before signing this consent form. The terms of the Notice of Privacy Practices may change from time to time. You can get a copy of the latest Notice of Privacy Practices by contacting our office. We also will post a copy of our current Notice of Privacy Practices in our office.


You have the right to request that we restrict how we use or disclose protected health information to carry our treatment, payment, or health care operations. We do not have to agree to such requests, but must honor the requests to which we agree.


You have the right to revoke this consent in writing, and the revocation will become effective except to the extent that we acted in reliance on your consent.


You have the right to participate in Telemedicine care with Harmony With Food/Nutritionally Sound LLC and understand and agree that any internet breach of information is not the responsibility of Harmony With Food/Nutritionally Sound LLC.


By signing below, you hereby consent to our use of your protected health information to carry out treatment, payment, and health care operations, and acknowledge receipt of a copy of this consent if requested.

You can leave a message on my home phone/ cell phone
Yes
No
It is acceptable to contact me by email
Yes
No

Note: Email contact is for your benefit only. Information is not shared without additional consent from you; however, email exchange is not inherently secure.

Cancellation Policy

Please Read Carefully

Once an appointment is scheduled you are expected to pay out of pocket for the full fee which is equivalent to the reimbursement by your insurance company plus the co-payment without a 48-hour notice of cancellation (this also includes if you are more than 15 minutes late without proper communication). (The fee is $150 minimum-$300 maximum). You must provide your credit card of choice below. Your card will be automatically charged at the time an appointment is cancelled without 48-hour notice of cancellation (an appointment is considered cancelled if you are more than 15 minutes late and there was no prior communication regarding the tardiness).



In the event you need to cancel an appointment, please call and leave a voicemail on the office line: 401-245-8784 ext. 1. DO NOT email any cancellations.

Your signature below indicates that you have read this policy and agree to its terms.

OR

Thank you. We appreciate your business.


updated 4/30/2025

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