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If you’d like to be considered for an appointment, please complete all the questions below.

Be sure to print your name and date to give consent for dietetic support.



    By submitting this form, you agree to be motivated and dedicated to take action.

    You also agree to our privacy policy.

    We aim to contact you within 2 working days.

    This information is required to obtain your contact details and help the Dietitian assess your personal needs. This will also maximise the initial breakthrough session, which is totally FREE.

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    CONSENT FORM – PRIVACY INFORMATION

    This privacy information as part of the consent form sets out how CharlieJeane uses and protects any personal information that you provide us.

    CharlieJeane is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using our services, you can be assured that it will only be used in accordance with this privacy statement.

    Why we collect your data:
    We collect your personal data because you give us consent to do so, in order to provide our specialist nutritional services to you.

    What we collect:
    We may collect the following information:
    · Information in relation to this consent form;
    · Medical and lifestyle information, through conversation, observation and questionnaires;
    · Further clinical information in relation to reports from other health professionals.

    What we do with the information we gather:
    We require this information for the purpose of:
    · Communicating with you regarding your treatment;
    · Professional clinical record keeping of patient information;
    · Creating fully informed reports and treatment plans for you;
    · Sharing information with relevant health professionals.

    Security
    We are committed to ensuring that your information is secure. In order to prevent unauthorised access or disclosure, we have put in place highly secure electronic systems and managerial procedures to safeguard and secure the information we collect.

    Controlling your personal information
    We will not distribute, sell or lease your personal information to third parties unless we have your explicit permission or are required by law to do so.

    You may request details of personal information which we hold about you under the General Data Protection Regulation (GDPR). If you would like a copy of the information held on you please contact Charliejeane Cooke, Data Controller, at hello@charliejeane.com.

    If you believe that any information we’re holding on you is incorrect or incomplete, please email or write to us as soon as possible at the above address. We will promptly correct any information found to be incorrect.

    Data Retention
    We will retain your personal data for 7 years after you stop using our services, unless there is justification for us to retain it for a longer period.

    How you can withdraw and request to be deleted from our files
    If you do not wish us to make use of your Personal Information in this way, please contact Charliejeane Cooke, or email hello@charliejeane.com. You have the right to withdraw consent.