SPA FEMME SIGNATURE WELLNESS INTAKE

Welcome to the SpaFEMME Signature Wellness Experience. This comprehensive intake helps us better understand your symptoms, goals, hormone health, metabolic wellness, stress patterns, and aesthetic concerns so we can personalize your care recommendations and advanced lab testing.

We believe your care journey should be personalized to your goals, lifestyle, and vision for your health and confidence.

Thank you for completing your SpaFEMME intake form. Your responses will help us personalize your lab recommendations, clinical review, and next steps within your wellness journey. Once reviewed, our team will contact you regarding recommendations and scheduling.

Please read carefully and sign below to indicate your understanding and agreement.

 

I acknowledge and consent to the following:

 

Accuracy of Information:
All information provided by me in this comprehensive intake form is true, complete, and accurate to the best of my knowledge.

Clinical Use of Information:
My responses will be reviewed confidentially by Spa Femme clinical providers to formulate personalized health and wellness recommendations, including functional labs, treatment strategies, and lifestyle guidance.

Laboratory Testing & Personalized Care:
I understand Spa Femme utilizes targeted functional lab testing to customize wellness programs and recommendations. I will be informed of any costs associated with lab tests before they’re ordered. Results will be discussed in detail during my follow-up consultation.

Scope of Practice:
I understand that services provided by Spa Femme, including those provided by Charlette Withers, MSN, CNM, are wellness-focused and functional in nature, and are not a substitute for primary medical care. I acknowledge my responsibility to continue routine healthcare and screenings with my primary care provider.

Financial Agreement:
I agree to pay fees associated with consultations, labs, and wellness services as outlined clearly by Spa Femme. Payment is due before lab ordering and delivery of treatment plans unless otherwise agreed upon.

 

Privacy & HIPAA Compliance

Spa Femme adheres strictly to HIPAA regulations and is committed to maintaining the confidentiality of your health information. Your personal and medical information will not be disclosed without your written permission, except as required by law.

By submitting this form, I understand and agree that:

 I am providing protected health information (PHI) voluntarily.
This information may be used by Spa Femme providers to assess, evaluate, or recommend personalized wellness services.

All submissions are stored securely in accordance with HIPAA guidelines.

 

Cancellations and No-shows:

I understand Spa Femme has a cancellation policy requiring at least 24 hours’ notice for any changes to appointments. Failure to do so may result in a cancellation fee.

 

NON-REFUNDABLE SERVICE POLICY

 

By submitting payment, I understand and agree that all clinical consultation fees—including intake review, virtual consultations, and personalized lab panel creation—are non-refundable. This includes services rendered during the Signature Intake process, such as review of symptoms, clinical analysis, and selection of lab tests tailored to my health goals.

 

I acknowledge that once services have been rendered, including but not limited to personalized lab ordering and intake consultation, no refunds will be issued—even if I choose not to complete the recommended labs.

 

If labs are ordered through a third-party lab provider (e.g., Rupa Health), any refunds for the lab portion are subject to the lab company’s cancellation and refund policies. Refunds, if applicable, may be limited to the cost of the lab tests only and will not include consultation or processing fees.

 

In cases of documented medical or emergency situations, SpaFEMME reserves the right to review exceptions at its discretion.

 

☐ I have read and agree to the Non-Refundable Service Policy.