Functional Medicine Intake

I understand that functional wellness services are educational and supportive and may include history review, nutrition and lifestyle counseling, wellness coaching, review or recommendation of appropriate laboratory information, and personalized wellness planning. They do not replace emergency care, primary medical care, specialist treatment, psychiatric care or prescribed medication management. No diagnosis, cure or specific outcome is guaranteed.

I understand nutrition and supplement recommendations may have risks, benefits, alternatives, interactions or contraindications. I agree to inform the clinic about prescriptions, pregnancy, allergies and medical conditions and to consult the prescribing clinician before changing any medication. I may decline any recommendation.

I understand recommended laboratory testing may involve separate laboratories, fees and specimen requirements. Testing will be discussed before ordering. Program fees, included laboratory allowances, specialty testing and cancellation/refund terms should be confirmed in a written financial agreement before services begin. Insurance coverage is not guaranteed.

I acknowledge that I have been offered access to the Notice of Privacy Practices. I certify that the information provided is accurate and complete to the best of my knowledge and agree to update the clinic about meaningful changes.