CLIENT AGREEMENT SARAH MATHIS WELLNESS LLC 

 

In order to best serve you, the Client Acceptance Policy should be carefully reviewed. It is our opinion that you should be well informed on our expectations and recommendations. To prevent any misunderstandings or confusion on what to expect, we would appreciate that you read the below steps and provide your signature. This will attest to the fact that you have read the Client Acceptance Policy and understand what is expected of you, as well as what to expect from working with us.

 

It is very important for you to carefully and thoroughly complete all of the new patient forms and questionnaires prior to your first consultations

 

The questionnaires supplied to you to complete were developed to gather important information about your previous medical care, current health complaints, lifestyle, eating habits and mindset. It will  assist us in helping you. These questionnaires will allow your consultant to correctly pinpoint the most probable explanations of your health symptoms. However, your health consultants and coaches are in no way diagnosing, treating, or acting as a medical professional, even if he/she may contain an active medical licensure. You will be given recommendations only, and no medical treatment will take place.

 

Please review the below:

 

1. We will not be ordering any insurance covered services, or filing for your insurance. No ICD-10 codes will be supplied, as this is in no way diagnosing or treating.
2. If you have not had a physical examination within the last year or since the start of your most recent health problem, it is highly recommended to schedule an appointment with your primary physician within a reasonable time after starting with the consultation process, as your team will not be doing any physical examination or seeing you in person. Other things such as ultrasounds, scans, or traditional laboratory testing would also be completed outside of this contract with you, we will not order or prescribe any such testing.

 

3. The results of your lab tests may take up to approximately three weeks. You will be presented with a copy detailing the results of your tests at the scheduled appointment, not prior to.

 

4. Correspondence by e-mail or other means is acceptable and encouraged for any questions. Note that any correspondence via text, email, phone, video, Facebook, Instagram, or any other means during and after your entire relationship with us is not HIPPA or medically secure, and you share information on these platforms willingly.

 

5. We will do the best to accommodate all scheduling needs. It is your responsibility to reach out and inquire about setting up a time for your appointment, or scheduling if nothing is available on the online calendar provided.

 

6. Payment for this package must be paid in full, or in the agreed upon means. No services will be provided prior to payment.

 

7. There will be no refunds of payment, for any reason, despite it the client completes his/her time with us.

 

8. Once laboratory work is sent out to the client, you are responsible for completing it in a timely manner. Please let your clinicians know right away if you will not be able to complete laboratory testing for an extended period of time for any reason.

 

AUTHORIZATION OF CONSULTATIONS:

 

I, _____________________________________, hereby authorize health, mindset, lifestyle, and nutritional, and other such consultations for myself or my minor child by SARAH MATHIS WELLNESS LLC.

 

NOTICE AS TO NATURE OF SERVICES: I seek the health consultation services of the Company, employees and staff. I understand that this team uses some recommendations that some may be considered holistic, complementary or alternative. Some of these methods have not been accepted by mainstream medicine. I understand that the principles of this practice are based on Functional Medicine, a health system, in which we believe that the body has an inherent ability to heal itself given the right tools. Not all treatment modalities provided by team members are based on science-based evidence. In no way is this team asserting or implying to holding themselves out to be a Medical Doctor of Osteopathic Medicine (DO), Nurse Practitioner (NP), or any other medical professional in this consulting relationship. Furthermore, the term “patient” may be utilized, and is understood as a customary term and does not imply or expressly constitute a conventional doctor/patient relationship has been established. The term “client” will be most solely used. I fully understand that the advice and recommendations that are provided by SARAH MATHIS WELLNESS LLC  are not to be considered medical advice and are for informational and educational purposes only.

 

Some of the recommendations and thoughts that are used by Sarah Mathis Wellness LLC include the following:

 

1. A person’s lifestyle including his or her diet, exercise patterns, sleep habits and stresses are believed to be related to the development and maintenance of illness. Your team will evaluate these factors and seek to help the client give up negative lifestyle patterns and establish more positive ones regardless of age or type of medical problem.

 

2. Although prescription and over-the-counter medications are used when a physician believes it is necessary, an attempt will be made to use products that are naturally familiar to the body. These include but are not limited to, nutritional supplements such as vitamins, minerals, enzymes, amino acids, essential fatty acids and foods.

 

3. Because your team will look for imbalances in the body and for trends that may result in illness if not addressed, tests are sometimes ordered that may be considered by consensus mainstream medicine to be either unnecessary or of no value. These may include tests for nutritional status, such as blood levels of vitamins and minerals, hormone levels, tests for heavy metals or tests for allergies.

 

4. Our team feels that environmental factors may play a major role in health and disease. Some of the diseases of unknown cause may be triggered or perpetuated by common environmental substances, many of which are man- made. Individuals may vary greatly in their susceptibility to various substances, so that one individual may be made deathly ill by an exposure to a substance 

while another is not at all affected. Your clinicians will attempt to identify offending substances and help patients to detoxify from past exposures that are affecting them.

 

5. Your team very much believes in a person being involved in their own health care and encourages questions, exploration and participation in decisions.

 

6. Exercise is important in maintaining health and promoting wellness as well as helping one to recover from an illness. Graded exercise, both aerobic and stretching, is encouraged for most patients. We advise that you consult your primary care physician and complete a comprehensive physical exam before engaging in any such activities.

 

7. Sometimes medications are recommended that are approved by the FDA to treat one condition; however, that same medication may be used for treatment that has not been FDA approved. We will not and cannot prescribe any medications due to the nature of this relationship being that of consultation only.

 

NOTICE THAT SERVICES ARE NOT PRIMARY CARE: I understand that no physician or any other practitioner that I see through the Company is acting as my primary care physician. As such, emergency services are not offered. I understand that even though my consultants may address issues affecting my general health, the practice is focused on a complementary, functional, holistic approach to health care and it is required to have a primary care physician to ensure that I am fully appraised of all available conventional means to address any medical conditions that I may have.  This is also important because these practices are exclusively virtual-based and are not affiliated with a hospital. If I become so ill that I require hospitalization, it is vital that I have a primary care physician with hospital admitting privileges familiar with my health problems and history. I understand that in addition to a primary care physician, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children.

 

NO GUARANTEES: I understand that the Company does not make any representations, claims or guarantees that I will be helped with my medical problems or conditions by undergoing consultations with them. However, they will do the best to help me accomplish my health and wellness goals.

 

REVOCATION OF AUTHORIZATIONS: These authorizations will remain active unless revoked by me in writing at any time. I understand such revocation will not affect my financial responsibility to pay for services rendered.

 

NUTRITIONAL SUPPLEMENTS: I understand that the Company and team members will make nutritional supplements and other recommended products available. Many of these products are not available through retail outlets. These are provided for the convenience of clients. I am in no way obligated to purchase these products from my consultant. I am free to purchase any recommended supplements or other products from any source that I choose. I further understand that my consultants make no statement expressed or implied about any product recommended that it is intended to diagnose to treat any disease. No statements made by the Company are evaluated by the FDA.

 

INSURANCE CLAIM MANAGEMENT: We do not participate nor are contracted with any insurance company. We will not provide a receipt and an encounter form to submit to insurance, and do not prepare or submit insurance claim forms. We are not obligated to respond to insurance carrier requests for information, and are not obligated to take action on my behalf against an insurance carrier for collecting or negotiating my any claim.

 

I am responsible for the payment of services provided by the Company at the time of service without regard to insurance coverage. I am entitled to know the cost of all services and procedures in advance and it is my responsibility to ask if they are not told to me.

 

FINANCIAL INSURANCE RESPONSIBILITY FOR ALL SERVICES: I understand my responsibility to pay includes fees for laboratory and/or other clinical diagnostic testing and/or services requested by the Company. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for the Company to take action to secure payment of an outstanding balance owed.

 

Any and all past due patient balances, if applicable, will be collected before my appointment. In addition to the fee for consultations, the cost for lab work or other specialized testing deemed appropriate to my case will be applied to my balance if necessary.

 

We are committed to providing the best consultations for clients. All appointments are considered confirmed at the time they are made. I understand all payments must be made prior to appointment time. Because a substantial amount of time has been set- aside for me, I will forfeit any charges for a missed appointment. If an appointment is missed, I am not guaranteed a make-up appointment for that week, it is my responsibility to re-schedule, and my allotted time with the Company will not be extended, under any circumstances. If I need to miss appointments due to illness, vacation, travel, or family emergencies, I am not guaranteed additional appointments to make up for that time, and will still be responsible for the cost of that appointment. I understand that I need to make my best attempt to contact my consultant 48 hours in advance if I cannot keep the appointment.

 

It is clear that there will be no refunds for any services agreed upon by myself and the Company. If I pay in full and am unable or unwilling to complete my time with this company, regardless of how much time, if any, we have spent together, I do not receive a refund for my payment. If I am on payment plans, I fully agree and understand that I am responsible to fulfill all monthly payments on the first of each month, and I will not be given any consultations or email access until that payment is complete. If I am on payment plans, I certify that I will complete all months of payment regardless of if I complete my work with my consultants, or discontinue services, and regardless if I miss an appointment, or even entire months with my clinicians regardless of what the reasoning may be. In addition, if I miss an appointment, or multiple appointments due to any reason, I will not be granted additional time onto your package. I am fully aware there are no “pauses” in my when I sign on as a client, my time with the Company is for consecutive months, with no exceptions. If I must miss a month or multiple months, I do not get reimbursed for that payment or time. There are no partial refunds. If a payment plan is chosen, I understand I am fully responsible for payment the first and last month in full up front, prior to my first appointment.

 

CLIENT ACKNOWLEDGEMENT: I certify that I am here to receive consultation services only and/or they are not substitutes for appropriate medical care. I do not represent any third party. I have read, understood 

TERMS AND SERVICES: Client agrees to pay the Company a total amount of One Hundred Eleven Dollars  ($111) USD, which shall be paid in ONE(1) payment. The first payment being the date the Client agrees and executes to the terms of this Agreement of  Fifty  Dollars ($50) USD paid via wire transfer or the agreed upon method of payment. The duration of the program will be one (1) visit 1:1 with Sarah Mathis for thirty (30) minutes.,  After the duration of the program the Client will no longer be coached or have access to coaching portals. However, the Client may keep any downloaded materials, etc. that they utilized during the program. This is NOT a full protocol call. This session functions as a mini consultation to review your health history, symptoms and strategy for the next steps of your healing. 

If you decide to upgrade to a full initial deep dive call, Client agrees to pay the Company a total amount of Four Hundred Fifty Dollars ($450) USD, which shall be paid in ONE (1) payment. The first payment being the date the Client agrees and executes to the terms of this Agreement of  Four Hundred Fifty Dollars ($450) USD paid via wire transfer or the agreed upon method of payment. The duration of the program will be one (1) visit 1:1 with Sarah Mathis for twenty (20) minutes.,  After the duration of the program the Client will no longer be coached or have access to coaching portals. However, the Client may keep any downloaded materials, etc. that they utilized during the program.

 

1. Additional costs. Additional costs for food preparation and delivery, non-toxic home products, recommended DVDs, guides and other expenses recommended to the Client’s personalized protocol are not included in the service fee and such cost shall be the sole responsibility of Client. This service fee is solely for the cost of consultation services. 
2. Timeliness of Costs. Each payment made by Client under this Agreement must be received by Sarah Mathis Wellness LLC on the date specified in this Agreement. If payment is not timely received within five (5) business days of the payment date set forth in Paragraph 4 above. Client shall have materially breached the Agreement and shall forfeit all remaining portion of services that have not yet been performed under the agreement. Sarah Mathis Wellness LLC shall have no further obligation to Client. In addition, if payment is not timely made by Client according to the Agreement, the past due amounts shall accrue interest of 1.5% (one and a half percent) monthly (compounded) beginning on the day following the due date until fully paid and may be placed in the hands of an attorney for collection or collection agency. The Client agrees to Sarah Mathis Wellness LLC all reasonable attorneys’ fees and costs associated with collection fo the past due amounts, which include collection agency costs of 25% (Twenty-five percent) of all past due amounts placed in the hands of the collection agency.  
3. Refunds. Client is not entitled to a refund or chargeback for any reason. All payments made to Sarah Mathis Wellness LLC pursuant to this Agreement are final and not refundable for any reason. 

I understand that I have the right to review this consent with an attorney if I choose before accepting any consultation or services. I have executed this consent freely and willingly understand its provisions. I recognize that the Company will rely upon my signing of this document in accepting me as a client and establishing me under legal contract. I acknowledge receipt of a copy of this consent if I have requested it.

I do hereby acknowledge that by signing this statement of understanding that I understand that some, and perhaps all, of the consulting, medical, preventative, nutritional, and diagnostic consultation provided may be innovative, non-traditional or unconventional and is consulting only and not to be construed to qualify as medical or nutritional advice and it is for informational and educational purposes only. I also understand that these unconventional services may be viewed by 3rd party insurance purveyors as non-covered services, in that they might be considered unreasonable or unnecessary under any medical insurance program. I also realize that my insurance coverage does not pay for such services and that I will be personally responsible for payment. I understand that I will pay all costs including reasonable attorney fees, should that become necessary. I understand that all outstanding balances bear interest at the maximum rate allowed by law.

 

I understand that by checking the box represents my signature that provides my full informed consent for any and all treatments, services, and recommendations offered and given to me or my minor and that I will not be required to sign individually separate consent forms for any protocols or recommendations received during time with the company.