The intent of any and all services offered and/or nutritional protocols or lifestyle recommendations suggested the NYCFM team is designed tosupport the natural physiological & biochemical processes of the human body. The purpose is not to diagnose, treat, prevent or cure any disease. All suggested protocols are from a holistic perspective. As such, NYCFM does not act as your primary care physician and you must continue to have a medical PCP and keep them informed of all your healthcare activities.
Our Health Consultants can see clients in all states of the U.S.Please make sure you are scheduled with the correct practitioner per our website listing. Any questions? Contact the office at Team@Nyfunctionalmed.org.Health Coaches may provide coaching and consulting regarding nutrition, supplementation recommendations, lifestyle changes, and health education but does not create a doctor-client relationship. You must always have a Primary CarePhysician that you work with in your hometown even if consulting with one of our MD/PhD/DC/DO/ND Consultants. You agree to keep your doctor informed of all your health and lifestyle changes. Be especially mindful if you take prescriptions and lose weight as many prescribe based on weight.
By scheduling with NY Center for Functional Medicine and by signing this agreement I acknowledge that I am agreeing to participate in telehealth consultation (tele-consults) with the Nutrition Consultants and/or staff at NY Center for Functional Medicine (NYCFM). I am seeking this tele-consult for my own purposes and not on behalf of any third party. Iunderstand the risks, benefits, limitations and alternatives to tele-consults(including the option to seek a different practitioner for in-person services) and have chosen of my own free will to participate in tele-consults with NY Center for Functional Medicine. I understand I am a participant in the decision-making process and I am free to decline any service/treatment/recommendation/suggestion offered by the NYCFM team at anytime. I accept that the NYCFM team may at any time refer me to a different office if the nature of my consultation is inappropriate for tele-consults. I understand that tele-consults typically involve the use of audio and/or video or other technology between me and the Consultant. Due to the nature of tele-consults, visits are largely educational and rely heavily on the client history and laboratory findings. Exam and vital findings via video or phone are limited in nature vs an in-person examination.
We request a minimum of 48 hours advance notice for any cancellation or rescheduling of your appointment. This is a consideration to our consultants. Short notice or no notice will result in an office visit charge at the regular rate.
Payment in full is expected at the time of scheduling or at the time of service. NY Center for Functional Medicine receives payment in cash, check, credit and debit card form. There is a $25.00 fee for returned checks. There are no service refunds. You agree that your credit card on file will be automatically charged for any NY Center for Functional Medicine invoice generated such as your visit fee or if a supplement order or lab order is requested. You also authorize NY Center for Functional Medicine to automatically charge your credit card for any missed appointments or late cancellations of less than 48 hours in advance at the full service fee. There is no charge for rescheduling or canceling appointments more than 48 hours in advance. I am also responsible for any chargeback fees if for some reason my credit card is declined. This authorization is part of my records and will be treated with privacy, confidentiality and respect.
If a visit goes over the scheduled time (ex. 1 hour) then there will be an additional visit charge in 15 minute increments at the prorated rate. Your credit card on file will be charged after the visit is complete.
Supplements and Lab work is purchased through outside vendors andNYCFM can not issue any refunds, please only purchase items you intend to use.There are no refunds for services that have already been fulfilled (ex. after a visit) or not. If you purchase a set of visits/services for a discount in a"package plan" and decide to not use them all - you will not receive a refund for any remaining balance after calculating the used visits at the normal fee schedule. You may receive a refund for a prepaid visit if NYCFM cancels the appointment.
NY Center for Functional Medicine does not act as a primary care physician and is not on call, nor are any NY Center for Functional Medicine consultants regardless of license type including MD/DO/DC/ND/PhD. Please maintain a positive, working relationship with your medical doctor, keep him/her informed of your healing activities and continue your regular medical care and check-ups. This applies to all providers within NY Center forFunctional Medicine.
Our visits are currently being held remotely and have no risk of exposure to Covid-19 and/or any virus. For visits held in person, we follow strict guidelines per the State of CA. Surfaces are wiped down between visits and gloves are worn when indicated. We ask that clients/clients do NOT come to an in-person visit if they have traveled within the last 14 days, have been exposed to someone positive with Covid-19 or have symptoms including cough, fever and loss of taste or smell. If you choose to have an in-person appointment you understand that there is still risk of exposure, by attending the in-person visit you assume all risks related to exposure to Covid-19 and agree to not hold NY Center for Functional Medicine liable for any illness or injury.
You agree to authorize NY Center for Functional Medicine to use any public reviews (ex. Google, Yelp, Facebook, etc) that you submit or a review emailed to us. These reviews may be used for marketing activities and other online promotions via social media, websites and all printed or digital publications and media in perpetuity. You acknowledge that participation is voluntary, there is no financial compensation and this includes photos, graphics and testimonials. You release NY Center for Functional Medicine of any liability or claims by me or any third party related to the use of photographs, graphics or testimonials in printed or digital media.
All current updates to our Policies will be immediately applicable to you & all previous signers and posted on the NY Center forFunctional Medicine website and in our Jane software. You may view them there or request an updated copy emailed to you at any time.
NY Center for Functional Medicine consultants will **NOT** take you off any medication, which can only be done with your prescribing physician.If your goal is to decrease your need for medication, we can suggest a protocol to encourage health and then you may work with your MD to monitor your progress and see if you are able to lower or eliminate your medication dosage over time.Keep your MD informed.
In case of an emergency, call your PCP, visit your local urgent care or call 911.
**OFFICE SERVICES**
NY Center for Functional Medicine (**NY Center for FunctionalMedicine or NYCFM**) offers a variety of holistic care and/or coaching services including Nutrition, Bodywork, Massage Therapy, Health Coaching, FunctionalNutrition, Nutritional Lab Education, all through Nutrition Consultants operating within their scope of practice. All of these holistic services are collectively referred to as Nutrition Consulting/Coaching.
**INFORMED CONSENT FOR NUTRITION CARE (Which includes all items mentioned above).**
To the client (or their legal guardian, court-appointed conservator, or agent): Please read this entire form prior to signing it. Please ask any questions prior to signing this form if you are unclear about anything in this form.
**Updates to Informed Consent** All current updates to our InformedConsent will be immediately applicable to you & all previous signers and posted on the NY Center for Functional Medicine website and in our Jane software. You may view them there or request an updated copy emailed to you at any time.
No Guarantee - Results Dependent on Consultant
We can not guarantee results but will share good practices that have been effective in our clinical experience and in practice by those we have coached and worked with over the years. It will always be incumbent on you to “do the work”, to do your research and take action steps.
Our team may share experience and practical stories based on their practice or those of clients they have coached or what is considered standard in the industry. However, we are not an attorney and none of the advice shared constitutes legal or tax advice. Please consult legal advice or tax advice when/as needed and note that the laws may different by your county, state or country and often differ by medical license.
Care During Pandemic Our visits are currently being held remotely and have no risk of exposure to Covid-19 and/or any virus. For visits held in person, we follow strict guidelines per the State of CA. Surfaces are wiped down between visits and gloves are worn when indicated. We ask that clients doNOT come to an in-person visit if they have traveled within the last 14 days, have been exposed to someone positive with Covid-19 or have symptoms including cough, fever and loss of taste or smell. If you choose to have an in-person appointment you understand that there is still risk of exposure, by attending the in-person visit you assume all risks related to exposure to Covid-19 and agree to not hold NY Center for Functional Medicine liable for any illness or injury.
All current updates to our Policies will be immediately applicable to you & all previous signers and posted on the NYCenter for Functional Medicine website and in our Jane software. You may view them there or request an updated copy emailed to you at any time.
