Sevi Rutgrink – Keto Coaching

Informed consent

Informed consent declaration Sevi Rutgrink – Keto Coaching

The undersigned:

Born on:

Resident address:

  • Declares that he/she has been fully informed about the abilities and possibilities offered by Sevi Rutgrink – Keto Coaching in her work as a keto coach;
  • The undersigned has truthfully answered all questions asked by Sevi Rutgrink – Keto Coaching during the intake and has also provided all relevant medical information;
  • The undersigned has been fully informed in advance of the costs of keto coaching as also stated on the website
  • The undersigned is fully aware of and agrees to the terms and conditions as stated on the website
  • The undersigned is fully aware of and agrees to the disclaimer as stated on the website; the medical part of this disclaimer can also be found at the bottom of this form;
  • The undersigned further declares that he/she has agreed to the objective of keto coaching and is aware that the results of the coaching depends, inter alia, on his/her own efforts;
  • The undersigned further realises that there is no obligation to achieve results but rather an obligation to perform to the best of one’s abilities on the part of Sevi Rutgrink – Keto Coaching;
  • The undersigned is aware of the confidentiality of the information given: that which is discussed between coach and client during keto coaching will not be shared with third parties;
  • The undersigned is familiar with the privacy and cookies statement as stated on the website
  • The undersigned retains the right to inspect his/her file;
  • The undersigned knows that his/her permission is always required for sharing information with third parties; examples are the general practitioner, a specialist or another therapist in case of transfer and/or referral;
  • The undersigned is of the opinion that he/she has received answers to all questions that came up in connection with the intended keto coaching program;
  • The undersigned declares that, on the basis of all the information obtained, he/she has reached a well-considered decision to enter into a keto coaching program.



Signature of client:

Medical disclaimer

The contents of the website and the advice given during a keto coaching program are not intended as treatment or prevention method of any illness, nor as a replacement of medical treatment or as an alternative for medical advice. Use of the advice given on the aforementioned website or during a keto coaching program followed by you is at your own risk. It is always advisable to discuss a transition to a keto lifestyle with your general practitioner or any other relevant medical caregiver.