Sample Financial Agreement Form

When setting up your nutrition private practice, it’s important to clearly communicate with your clients upfront about your practice financial policies. This is usually wrapped up in a “Financial Agreement,” form. It will help ensure that your client is fully aware of how they will be billed how their billing information will be used and what they will be responsible for paying. This eliminates the need for awkward financial conversations and ensures that you are paid for your services in a timely manner.

Some policies that are generally included in a nutrition financial agreement policy form:

  • If you are insurance-based, your financial agreement form should speak to portions of the services your clients may be responsible for at the time of service: including deductibles and/or copays
  • Who is responsible for confirming insurance coverage (usually it is the client’s responsibility)
  • Agreement of the client to pay for any portion of their services insurance does not cover
  • How payments can be made to your practice (check, credit card, cash, etc)
  • When self-pay payments are expected to be paid (ie. at time of service, or within a certain time-frame)
  • An agreement to your cancellation policy terms (or you can create a separate Cancellation Policy)
  • What your policy on issuing refunds are

Download our sample Financial Agreement form below, but be sure to have legal consult review it, and make adjustments based on your business legal needs. You’ll want to tailor this template to speak to your nutrition practice’s policies and procedures.

Back to Top